Healthcare Provider Details

I. General information

NPI: 1710573613
Provider Name (Legal Business Name): BENJAMIN WUNDERLICH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2020
Last Update Date: 12/15/2020
Certification Date: 12/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2115 S MACARTHUR BLVD
SPRINGFIELD IL
62704-4501
US

IV. Provider business mailing address

2736 VIGAL RD
SPRINGFIELD IL
62712-5503
US

V. Phone/Fax

Practice location:
  • Phone: 217-726-1003
  • Fax:
Mailing address:
  • Phone: 618-334-0202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051294324
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: