Healthcare Provider Details

I. General information

NPI: 1154440238
Provider Name (Legal Business Name): MRS. ANITA JEAN REGENOLD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 E WASHINGTON ST
BLOOMINGTON IL
61701-4364
US

IV. Provider business mailing address

10405 E 1700 NORTH RD
PONTIAC IL
61764-3422
US

V. Phone/Fax

Practice location:
  • Phone: 309-661-5190
  • Fax: 309-661-7892
Mailing address:
  • Phone: 815-743-5785
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: