Healthcare Provider Details

I. General information

NPI: 1124933320
Provider Name (Legal Business Name): KENNETH COLE SIZEMORE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2026
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 E MAIN ST
CARBONDALE IL
62901-3140
US

IV. Provider business mailing address

13043 TALLEY TOWN ST
CARTERVILLE IL
62918-3489
US

V. Phone/Fax

Practice location:
  • Phone: 618-457-2033
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051.309266
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: