Healthcare Provider Details

I. General information

NPI: 1952236804
Provider Name (Legal Business Name): RICKY MAHAJAN
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2026
Last Update Date: 06/15/2026
Certification Date: 06/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 N MAIN ST
SAINT JOSEPH IL
61873-9355
US

IV. Provider business mailing address

204 N MAIN ST
SAINT JOSEPH IL
61873-9355
US

V. Phone/Fax

Practice location:
  • Phone: 217-469-2232
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051303640
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: