Provider Demographics
NPI:1104427707
Name:GILL, AMY NICOLE (RPH)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:NICOLE
Last Name:GILL
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3510 ROOSEVELT RD
Mailing Address - Street 2:
Mailing Address - City:TAYLORVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62568-8910
Mailing Address - Country:US
Mailing Address - Phone:217-827-3892
Mailing Address - Fax:
Practice Address - Street 1:2607 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62565-1235
Practice Address - Country:US
Practice Address - Phone:217-774-1571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-02
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051288308183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist