Healthcare Provider Details

I. General information

NPI: 1336139146
Provider Name (Legal Business Name): CHAD ASA BOHANNON RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

318 S PLAZA PARK
CHILLICOTHEE IL
61523-2214
US

IV. Provider business mailing address

13637 N WILD SPRUCE LN
CHILLICOTHEE IL
61523-9110
US

V. Phone/Fax

Practice location:
  • Phone: 309-274-9571
  • Fax: 309-274-8630
Mailing address:
  • Phone: 309-579-3242
  • Fax: 309-274-8630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: