Healthcare Provider Details

I. General information

NPI: 1629656905
Provider Name (Legal Business Name): ANDY RUAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2021
Last Update Date: 03/30/2021
Certification Date: 03/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 LARKIN AVE
ELGIN IL
60123-5947
US

IV. Provider business mailing address

9415 HARRISON ST
DES PLAINES IL
60016-1542
US

V. Phone/Fax

Practice location:
  • Phone: 847-695-1158
  • Fax:
Mailing address:
  • Phone: 773-931-4262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051292971
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: