Healthcare Provider Details

I. General information

NPI: 1710697743
Provider Name (Legal Business Name): JEREMIAH VANCE PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2022
Last Update Date: 11/30/2022
Certification Date: 11/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 N PROMENADE ST
HAVANA IL
62644-1243
US

IV. Provider business mailing address

615 N PROMENADE ST
HAVANA IL
62644-1243
US

V. Phone/Fax

Practice location:
  • Phone: 309-543-4431
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051304873
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: