Provider Demographics
NPI:1063796621
Name:RUTHERFORD, JEREMY (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:
Last Name:RUTHERFORD
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EAST PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61611-2016
Mailing Address - Country:US
Mailing Address - Phone:309-370-3538
Mailing Address - Fax:
Practice Address - Street 1:300 N MAIN ST
Practice Address - Street 2:
Practice Address - City:EAST PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61611-2016
Practice Address - Country:US
Practice Address - Phone:309-694-7661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-30
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0512914031835G0303X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835G0303XPharmacy Service ProvidersPharmacistGeriatric