Basic Information
| Provider Information | |||||||||
| NPI: | 1407451495 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROUWER | ||||||||
| FirstName: | SKYE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RPH | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| OtherMiddleName: | |||||||||
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| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 11200 LINCOLN HWY | ||||||||
| Address2: | |||||||||
| City: | MOKENA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604488208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8154642171 | ||||||||
| FaxNumber: | 8154642176 | ||||||||
| Practice Location | |||||||||
| Address1: | 11200 LINCOLN HWY | ||||||||
| Address2: | |||||||||
| City: | MOKENA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604488208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8154642171 | ||||||||
| FaxNumber: | 8154642176 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2020 | ||||||||
| LastUpdateDate: | 11/30/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 11/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | 051.291858 | IL | Y | Suppliers | Pharmacy |
No ID Information.