Healthcare Provider Details

I. General information

NPI: 1013520865
Provider Name (Legal Business Name): COLLEEN A MOBLEY PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2020
Last Update Date: 08/30/2020
Certification Date: 08/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 W RAAB RD
NORMAL IL
61761-1007
US

IV. Provider business mailing address

3305 CASTLEMAIN DR
BLOOMINGTON IL
61704-4844
US

V. Phone/Fax

Practice location:
  • Phone: 309-454-7347
  • Fax: 309-454-3915
Mailing address:
  • Phone: 309-287-5835
  • Fax: 309-454-3915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051.291132
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: