=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427868389
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELBRON ODISHO PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2025
-----------------------------------------------------
Last Update Date | 01/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19550 GOVERNORS HWY STE 3300
-----------------------------------------------------
City | FLOSSMOOR
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60422-2125
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-834-2285
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 711 S RIVER RD APT 315
-----------------------------------------------------
City | DES PLAINES
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60016-4769
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 224-716-9779
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 051305778
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------