Healthcare Provider Details

I. General information

NPI: 1306457239
Provider Name (Legal Business Name): NICOLE WALSH PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2020
Last Update Date: 08/13/2020
Certification Date: 08/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3564 RIDGE RD
LANSING IL
60438-3315
US

IV. Provider business mailing address

3564 RIDGE RD
LANSING IL
60438-3315
US

V. Phone/Fax

Practice location:
  • Phone: 708-895-7937
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051.298831
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: