Healthcare Provider Details

I. General information

NPI: 1992932107
Provider Name (Legal Business Name): ROSEMARIE ELEANA KOCH RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2009
Last Update Date: 06/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1343 W GREENLEAF AVE #2
CHICAGO IL
60626-2916
US

IV. Provider business mailing address

1343 W GREENLEAF AVE #2
CHICAGO IL
60626-2916
US

V. Phone/Fax

Practice location:
  • Phone: 773-262-4169
  • Fax:
Mailing address:
  • Phone: 773-262-4169
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051.288126
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: