Basic Information
| Provider Information | |||||||||
| NPI: | 1740291046 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | PHILLIP | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | RPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2754 W FITCH AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606453004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7737646419 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3001 GREEN BAY RD | ||||||||
| Address2: | 119 | ||||||||
| City: | NORTH CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600643048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476881900 | ||||||||
| FaxNumber: | 2246102958 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1835P1200X | IL | Y | Pharmacy Service Providers | Pharmacist | Pharmacotherapy |
No ID Information.