MEDICARE: MR. CHAD ASA BOHANNON 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		IL

General Provider Information

NPI Number	:	1336139146
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CHAD ASA BOHANNON RPH

Provider Business Mailing Address
First Line	:	13637 N WILD SPRUCE LN
Second Line	:
City	:	CHILLICOTHEE
State	:	IL
Zip	:	61523-9110
Country	:	US
Telephone Number	:	309-579-3242
Fax Number	:	309-274-8630

Provider Business Practice Location Address
First Line	:	318 S PLAZA PARK
Second Line	:
City	:	CHILLICOTHEE
State	:	IL
Zip	:	61523-2214
Country	:	US
Telephone Number	:	309-274-9571
Fax Number	:	309-274-8630

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

Provider Enumeration Date	:	10/24/2005
Last Update Date	:	07/08/2007

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Directions to “ MR. CHAD ASA BOHANNON RPH” Practice Location

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