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General NPI Number Information
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NPI Number | 1912500125
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Entity Type | Individual
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Provider Name | MR. DOMENICO GIUSTINO
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Gender | Male
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Dates
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Enumeration Date | 11/19/2020
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Last Update Date | 11/19/2020
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Provider Practice Location Address
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Address Line | 245 S BROADWAY ST
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City | COAL CITY
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State | IL
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Zip | 60416-1534
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Country | US
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Telephone | 815-634-0599
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Fax | 815-634-0686
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Provider Business Mailing Address
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Address Line | 8507 BROOKSIDE GLEN DR
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City | TINLEY PARK
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State | IL
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Zip | 60487-7044
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Country | US
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Telephone | 815-325-5441
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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 | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 051-040229
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License Number State | IL
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