Healthcare Provider Details

I. General information

NPI: 1558627323
Provider Name (Legal Business Name): QUEENSWAY ENT. INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2012
Last Update Date: 04/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

691 COLLINS ST SUITE 1B
JOLIET IL
60432-1856
US

IV. Provider business mailing address

PO BOX 4863
NAPERVILLE IL
60567-4863
US

V. Phone/Fax

Practice location:
  • Phone: 630-236-9502
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. RICHMOND NIMAKO-BOATENG
Title or Position: CEO
Credential: PHARM.D
Phone: 630-236-9502