Provider Demographics
NPI:1538405451
Name:POLWORT, JOAN M (RPH)
Entity type:Individual
Prefix:
First Name:JOAN
Middle Name:M
Last Name:POLWORT
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 1:801 BRAIDWOOD CT
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62234-1545
Mailing Address - Country:US
Mailing Address - Phone:618-345-8643
Mailing Address - Fax:
Practice Address - Street 1:801 BRAIDWOOD CT
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62234
Practice Address - Country:US
Practice Address - Phone:618-345-8643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-20
Last Update Date:2018-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO042676183500000X
IL051036802183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL051036802OtherPHARMACIST LICENSE