MEDICARE: DR. TOBIAS DOHERTY PHARMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	051300106	IL
2	183500000X	Pharmacist	1873940	WI

General Provider Information

NPI Number	:	1124569173
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TOBIAS DOHERTY PHARMD

Provider Business Mailing Address
First Line	:	1146 WINDBROOKE DR APT 202
Second Line	:
City	:	BUFFALO GROVE
State	:	IL
Zip	:	60089-2317
Country	:	US
Telephone Number	:	636-734-4007
Fax Number	:

Provider Business Practice Location Address
First Line	:	7701 GREEN BAY RD
Second Line	:
City	:	KENOSHA
State	:	WI
Zip	:	53142-4043
Country	:	US
Telephone Number	:	262-612-1610
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/09/2017
Last Update Date	:	03/09/2017

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