Provider Demographics
NPI:1972052645
Name:CHILDERS, SHERRY
Entity type:Individual
Prefix:
First Name:SHERRY
Middle Name:
Last Name:CHILDERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 QUAIL DR
Mailing Address - Street 2:
Mailing Address - City:HERRIN
Mailing Address - State:IL
Mailing Address - Zip Code:62948-2473
Mailing Address - Country:US
Mailing Address - Phone:618-694-9953
Mailing Address - Fax:
Practice Address - Street 1:1713 S PARK AVE
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-4166
Practice Address - Country:US
Practice Address - Phone:618-942-6641
Practice Address - Fax:618-988-9306
Is Sole Proprietor?:No
Enumeration Date:2016-09-23
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051039434183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist