MEDICARE: DIANE ADELE LEGRANDE 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	11690	KS
2	183500000X	Pharmacist	051039182	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	11690	OTHER	KS	KANSAS BOARD OF PHARMACY
2	051039182	OTHER	IL	ILLINOIS BOARD OF PHARMACY

General Provider Information

NPI Number	:	1821698929
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANE ADELE LEGRANDE RPH

Provider Business Mailing Address
First Line	:	1980 FREEDOM PKWY
Second Line	:
City	:	WASHINGTON
State	:	IL
Zip	:	61571-9468
Country	:	US
Telephone Number	:	309-745-3476
Fax Number	:	309-745-3487

Provider Business Practice Location Address
First Line	:	1980 FREEDOM PKWY
Second Line	:
City	:	WASHINGTON
State	:	IL
Zip	:	61571-9468
Country	:	US
Telephone Number	:	309-745-3476
Fax Number	:	309-745-3487

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

Provider Enumeration Date	:	10/28/2020
Last Update Date	:	10/28/2020

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Directions to “ DIANE ADELE LEGRANDE RPH” Practice Location

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