Healthcare Provider Details

I. General information

NPI: 1356822969
Provider Name (Legal Business Name): KENNETH B CAPULONG PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2018
Last Update Date: 08/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2746 N CLYBOURN AVE
CHICAGO IL
60614-1006
US

IV. Provider business mailing address

856 TAMARAC DR
CAROL STREAM IL
60188-4424
US

V. Phone/Fax

Practice location:
  • Phone: 773-360-2052
  • Fax:
Mailing address:
  • Phone: 630-965-5412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051301376
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number051301376
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: