Healthcare Provider Details

I. General information

NPI: 1750927687
Provider Name (Legal Business Name): DANIEL KOWALENKO PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2019
Last Update Date: 06/12/2024
Certification Date: 06/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 N ARIZONA AVE
GILBERT AZ
85233-1616
US

IV. Provider business mailing address

201 S MAIN ST
PEORIA IL
61611-2458
US

V. Phone/Fax

Practice location:
  • Phone: 480-293-0052
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051.298717
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: