Basic Information
Provider Information
NPI: 1174769756
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: ORSO
FirstName: ANTHONY
MiddleName: B
NamePrefix: MR.
NameSuffix:  
Credential: RPH
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 2401 W MAIN ST
Address2:  
City: MARION
State: IL
PostalCode: 629591188
CountryCode: US
TelephoneNumber: 6189975311
FaxNumber: 6189934188
Practice Location
Address1: 2401 W MAIN ST
Address2:  
City: MARION
State: IL
PostalCode: 629591188
CountryCode: US
TelephoneNumber: 6189975311
FaxNumber: 6189934188
Other Information
ProviderEnumerationDate: 01/02/2009
LastUpdateDate: 01/02/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
183500000X051034935ILY Pharmacy Service ProvidersPharmacist 

No ID Information.


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