Provider Demographics
NPI:1174557730
Name:GOTTRICH, RONALD W (RPH, MS)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:W
Last Name:GOTTRICH
Suffix:
Gender:M
Credentials:RPH, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 BELLERIVE RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-6800
Mailing Address - Country:US
Mailing Address - Phone:217-698-5938
Mailing Address - Fax:
Practice Address - Street 1:SAM'S CLUB PHARMACY 8215
Practice Address - Street 2:2300 WHITE OAKS DRIVE
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704
Practice Address - Country:US
Practice Address - Phone:217-698-5938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist