Healthcare Provider Details

I. General information

NPI: 1063796621
Provider Name (Legal Business Name): JEREMY RUTHERFORD PHARMD.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2011
Last Update Date: 09/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 N MAIN ST
EAST PEORIA IL
61611-2016
US

IV. Provider business mailing address

300 N MAIN ST
EAST PEORIA IL
61611-2016
US

V. Phone/Fax

Practice location:
  • Phone: 309-694-7661
  • Fax:
Mailing address:
  • Phone: 309-370-3538
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License Number051291403
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: