Provider Demographics
NPI:1982311031
Name:LAESCH, REBECCA KAE (PHARMD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:KAE
Last Name:LAESCH
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1357 IL ROUTE 127
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62246-3030
Mailing Address - Country:US
Mailing Address - Phone:618-699-1353
Mailing Address - Fax:
Practice Address - Street 1:1212 W MCCORD ST
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-5648
Practice Address - Country:US
Practice Address - Phone:618-533-1728
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-28
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051305200183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist