=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003199787
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHERRY A WULLER R.PH.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2011
-----------------------------------------------------
Last Update Date | 09/20/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 110 WALNUT ST
-----------------------------------------------------
City | HIGHLAND
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62249-1222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-651-1204
-----------------------------------------------------
Fax | 618-651-1217
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 110 WALNUT ST
-----------------------------------------------------
City | HIGHLAND
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62249-1222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-651-1204
-----------------------------------------------------
Fax | 618-651-1217
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 051287750
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 2003030477
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------