Healthcare Provider Details

I. General information

NPI: 1851112031
Provider Name (Legal Business Name): MADISYN TAYLOR SWIFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2024
Last Update Date: 10/21/2024
Certification Date: 10/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 WESLEY DR
WOOD RIVER IL
62095-1894
US

IV. Provider business mailing address

519 MONICA DR
LEBANON IL
62254-1769
US

V. Phone/Fax

Practice location:
  • Phone: 618-259-0293
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051306699
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: