Healthcare Provider Details

I. General information

NPI: 1720336092
Provider Name (Legal Business Name): JASON H MADIA PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2012
Last Update Date: 08/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2313 S MOUNT PROSPECT RD
DES PLAINES IL
60018-1811
US

IV. Provider business mailing address

3N845 BAERT LN
ST CHARLES IL
60175-7706
US

V. Phone/Fax

Practice location:
  • Phone: 847-635-3000
  • Fax:
Mailing address:
  • Phone: 630-945-3242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051290895
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: