Healthcare Provider Details

I. General information

NPI: 1407451495
Provider Name (Legal Business Name): SKYE BROUWER RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2020
Last Update Date: 11/30/2020
Certification Date: 11/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11200 LINCOLN HWY
MOKENA IL
60448-8208
US

IV. Provider business mailing address

11200 LINCOLN HWY
MOKENA IL
60448-8208
US

V. Phone/Fax

Practice location:
  • Phone: 815-464-2171
  • Fax: 815-464-2176
Mailing address:
  • Phone: 815-464-2171
  • Fax: 815-464-2176

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number051.291858
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: