Healthcare Provider Details

I. General information

NPI: 1578995361
Provider Name (Legal Business Name): RYAN IMEL PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2013
Last Update Date: 08/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 W COURT ST
PARIS IL
61944-1735
US

IV. Provider business mailing address

116 W COURT ST
PARIS IL
61944-1735
US

V. Phone/Fax

Practice location:
  • Phone: 217-465-8455
  • Fax:
Mailing address:
  • Phone: 217-465-8455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202212180
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051.295808
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: