MEDICARE: DR. DALTON PAUL DIECKOW 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	051.303137	IL

General Provider Information

NPI Number	:	1689509747
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DALTON PAUL DIECKOW PHARMD

Provider Business Mailing Address
First Line	:	8940 N WOOD SAGE RD
Second Line	:
City	:	PEORIA
State	:	IL
Zip	:	61615-7822
Country	:	US
Telephone Number	:	309-243-3404
Fax Number	:	309-243-3032

Provider Business Practice Location Address
First Line	:	8940 N WOOD SAGE RD
Second Line	:
City	:	PEORIA
State	:	IL
Zip	:	61615-7822
Country	:	US
Telephone Number	:	309-243-3404
Fax Number	:	309-243-3032

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

Provider Enumeration Date	:	06/17/2026
Last Update Date	:	06/17/2026

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