Healthcare Provider Details

I. General information

NPI: 1740291046
Provider Name (Legal Business Name): PHILLIP L NELSON RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 GREEN BAY RD 119
NORTH CHICAGO IL
60064-3048
US

IV. Provider business mailing address

2754 W FITCH AVE
CHICAGO IL
60645-3004
US

V. Phone/Fax

Practice location:
  • Phone: 847-688-1900
  • Fax: 224-610-2958
Mailing address:
  • Phone: 773-764-6419
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: