Healthcare Provider Details

I. General information

NPI: 1902187677
Provider Name (Legal Business Name): MARK ANDREW VIERKE R.P.H
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2011
Last Update Date: 09/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

395 S DIVISION ST
HARVARD IL
60033-3258
US

IV. Provider business mailing address

3213 BERRY ST
CRYSTAL LAKE IL
60012-1116
US

V. Phone/Fax

Practice location:
  • Phone: 815-943-4376
  • Fax: 815-943-4649
Mailing address:
  • Phone: 815-690-5490
  • Fax: 815-943-4649

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051-037677
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: