Healthcare Provider Details

I. General information

NPI: 1356626774
Provider Name (Legal Business Name): DOUGLAS NELSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2011
Last Update Date: 10/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7851 CATON FARM RD
PLAINFIELD IL
60586-1601
US

IV. Provider business mailing address

14123 MEADOW LN
PLAINFIELD IL
60544-1542
US

V. Phone/Fax

Practice location:
  • Phone: 815-436-2123
  • Fax:
Mailing address:
  • Phone: 773-620-3863
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051040829
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: