Healthcare Provider Details

I. General information

NPI: 1689509747
Provider Name (Legal Business Name): DALTON PAUL DIECKOW PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2026
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8940 N WOOD SAGE RD
PEORIA IL
61615-7822
US

IV. Provider business mailing address

8940 N WOOD SAGE RD
PEORIA IL
61615-7822
US

V. Phone/Fax

Practice location:
  • Phone: 309-243-3404
  • Fax: 309-243-3032
Mailing address:
  • Phone: 309-243-3404
  • Fax: 309-243-3032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051.303137
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: