=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649553561
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JONATHON ROSS CLOSEN PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2011
-----------------------------------------------------
Last Update Date | 09/27/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1200 E WAR MEMORIAL DR
-----------------------------------------------------
City | PEORIA HEIGHTS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61616-7723
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-684-3822
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2008 WESTGATE DR
-----------------------------------------------------
City | PEKIN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61554-2422
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-267-8682
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 051.294811
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------