=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518236942
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMY M PRUETT PHARM.D
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2011
-----------------------------------------------------
Last Update Date | 12/13/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 27155 W EAMES ST
-----------------------------------------------------
City | CHANNAHON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60410-5377
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-521-0326
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 26712 W ALLISON DR
-----------------------------------------------------
City | CHANNAHON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60410-5520
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-919-2791
-----------------------------------------------------
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 | 051.287191
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------