Healthcare Provider Details

I. General information

NPI: 1982207445
Provider Name (Legal Business Name): KASEY KOLB MERRITT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/18/2020
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

719 N WILLIAM KUMPF BLVD
PEORIA IL
61605-2530
US

IV. Provider business mailing address

7309 N EDGEWILD DR
PEORIA IL
61614-2113
US

V. Phone/Fax

Practice location:
  • Phone: 833-401-1679
  • Fax:
Mailing address:
  • Phone: 309-258-6158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051303588
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: