Healthcare Provider Details

I. General information

NPI: 1215486949
Provider Name (Legal Business Name): ELLEN HORNICKEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2016
Last Update Date: 09/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 W HARRISON ST
CHICAGO IL
60612-3714
US

IV. Provider business mailing address

4448 N SPAULDING AVE
CHICAGO IL
60625-5406
US

V. Phone/Fax

Practice location:
  • Phone: 312-864-6277
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051290434
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: