Provider Demographics
NPI:1902173198
Name:ATCHISON, JERRE DALE (RPH)
Entity type:Individual
Prefix:
First Name:JERRE
Middle Name:DALE
Last Name:ATCHISON
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 1:1900 STATE ST RM 100
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:IL
Mailing Address - Zip Code:62233-1116
Mailing Address - Country:US
Mailing Address - Phone:618-826-6134
Mailing Address - Fax:618-826-1708
Practice Address - Street 1:1600 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-2120
Practice Address - Country:US
Practice Address - Phone:618-457-8397
Practice Address - Fax:618-549-3052
Is Sole Proprietor?:No
Enumeration Date:2011-11-16
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051035825183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist