Provider Demographics
NPI:1326396771
Name:THOMPSON, GINA BERG (RPH)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:BERG
Last Name:THOMPSON
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 1:315 N WEBSTER ST
Mailing Address - Street 2:
Mailing Address - City:TAYLORVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62568-1555
Mailing Address - Country:US
Mailing Address - Phone:217-824-8154
Mailing Address - Fax:217-824-8165
Practice Address - Street 1:315 N WEBSTER ST
Practice Address - Street 2:
Practice Address - City:TAYLORVILLE
Practice Address - State:IL
Practice Address - Zip Code:62568-1555
Practice Address - Country:US
Practice Address - Phone:217-824-8154
Practice Address - Fax:217-824-8165
Is Sole Proprietor?:No
Enumeration Date:2012-08-15
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.035520183500000X
IN26014691A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist