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General NPI Number Information
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NPI Number | 1669974309
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Entity Type | Individual
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Provider Name | KELLY DECANIO
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Gender | Female
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Dates
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Enumeration Date | 03/07/2018
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Last Update Date | 03/07/2018
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Provider Practice Location Address
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Address Line | 1435 LAKE COOK RD
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City | DEERFIELD
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State | IL
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Zip | 60015-5213
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Country | US
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Telephone | 847-687-9974
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Fax |
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Provider Business Mailing Address
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Address Line | 5 BRENTWOOD DR
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City | HAWTHORN WOODS
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State | IL
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Zip | 60047-7402
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 051298728
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License Number State | IL
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