Healthcare Provider Details

I. General information

NPI: 1982311031
Provider Name (Legal Business Name): REBECCA KAE KUTCHMA PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2022
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1212 W MCCORD ST
CENTRALIA IL
62801-5648
US

IV. Provider business mailing address

PO BOX 158
HAMEL IL
62046-0158
US

V. Phone/Fax

Practice location:
  • Phone: 618-533-1728
  • Fax:
Mailing address:
  • Phone: 618-699-1353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051305200
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: