Healthcare Provider Details

I. General information

NPI: 1104109800
Provider Name (Legal Business Name): DALE SUHRENBROCK RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2011
Last Update Date: 09/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1122 VAUGHN RD
WOOD RIVER IL
62095-1848
US

IV. Provider business mailing address

805 CHANCELLOR DR
EDWARDSVILLE IL
62025-3936
US

V. Phone/Fax

Practice location:
  • Phone: 618-259-2013
  • Fax: 618-259-2098
Mailing address:
  • Phone: 618-830-0668
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051.031813
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number029774
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: