Provider Demographics
NPI:1285989673
Name:BRANNOCK, JASON K (RPH)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:K
Last Name:BRANNOCK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:565 KAREL PARK RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:IL
Mailing Address - Zip Code:62977-1528
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1021 US HIGHWAY 45 N
Practice Address - Street 2:
Practice Address - City:ELDORADO
Practice Address - State:IL
Practice Address - Zip Code:62930-3767
Practice Address - Country:US
Practice Address - Phone:618-273-3874
Practice Address - Fax:618-273-3843
Is Sole Proprietor?:No
Enumeration Date:2012-07-21
Last Update Date:2012-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.291023183500000X
KY012873183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist