MEDICARE: SHALU KOICKAL

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	051302758	IL

General Provider Information

NPI Number	:	1932700507
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHALU KOICKAL

Provider Business Mailing Address
First Line	:	1652 CLARA CT
Second Line	:
City	:	AURORA
State	:	IL
Zip	:	60502-4711
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	700 N 54TH ST
Second Line	:
City	:	QUINCY
State	:	IL
Zip	:	62305-7909
Country	:	US
Telephone Number	:	217-222-7369
Fax Number	:

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

Provider Enumeration Date	:	11/02/2020
Last Update Date	:	11/02/2020

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Directions to “ SHALU KOICKAL ” Practice Location

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