Healthcare Provider Details

I. General information

NPI: 1710824164
Provider Name (Legal Business Name): SHRIVETA BALRAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/04/2026
Certification Date: 05/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5140 W DIVERSEY AVE
CHICAGO IL
60639-1612
US

IV. Provider business mailing address

5140 W DIVERSEY AVE
CHICAGO IL
60639-1612
US

V. Phone/Fax

Practice location:
  • Phone: 773-685-8759
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051.307171
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: