MEDICARE: EDWARD J PRAISA JR. RPH

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	054004373	IL

General Provider Information

NPI Number	:	1164951646
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDWARD J PRAISA JR. RPH

Provider Business Mailing Address
First Line	:	101 N STATE ST
Second Line	:
City	:	MARENGO
State	:	IL
Zip	:	60152-2217
Country	:	US
Telephone Number	:	815-568-7242
Fax Number	:	815-568-0428

Provider Business Practice Location Address
First Line	:	101 N STATE ST
Second Line	:
City	:	MARENGO
State	:	IL
Zip	:	60152-2217
Country	:	US
Telephone Number	:	815-568-7242
Fax Number	:	815-568-7242

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

Provider Enumeration Date	:	06/08/2017
Last Update Date	:	06/08/2017

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