Healthcare Provider Details

I. General information

NPI: 1053851659
Provider Name (Legal Business Name): DR. ELIZABETH DENNISON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2017
Last Update Date: 03/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 W MAIN ST
MARION IL
62959-1188
US

IV. Provider business mailing address

3375 MOUNT MORIAH RD
GALATIA IL
62935-2602
US

V. Phone/Fax

Practice location:
  • Phone: 618-997-5311
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051294484
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: