Healthcare Provider Details

I. General information

NPI: 1396661823
Provider Name (Legal Business Name): CHRISTIAN JEFF BAGNAS MATIAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2026
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 FENCL LN
HILLSIDE IL
60162-2041
US

IV. Provider business mailing address

2235 EXETER CT
AURORA IL
60503-5574
US

V. Phone/Fax

Practice location:
  • Phone: 708-449-7600
  • Fax:
Mailing address:
  • Phone: 630-881-4218
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051.307954
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: