Basic Information
Provider Information | |||||||||
NPI: | 1326328030 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SALATA | ||||||||
FirstName: | NICOLE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHARMD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 7530 | ||||||||
Address2: |   | ||||||||
City: | LIBERTYVILLE | ||||||||
State: | IL | ||||||||
PostalCode: | 600487530 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8476504540 | ||||||||
FaxNumber: | 8475468048 | ||||||||
Practice Location | |||||||||
Address1: | 3311 N HALSTED ST | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606572412 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7734359583 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/25/2011 | ||||||||
LastUpdateDate: | 10/31/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/31/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 20069-40 | WI | N |   | Pharmacy Service Providers | Pharmacist |   | 183500000X | 051.294518 | IL | Y |   | Pharmacy Service Providers | Pharmacist |   |
ID Information
ID | Type | State | Issuer | Description | 051294518 | 01 | IL | REGISTERED PHARMACIST LICENSE | OTHER | 20069 | 01 | WI | REGISTERED PHARMACIST LICENSE | OTHER |