Provider Demographics
NPI:1366193625
Name:DARJI, KETUR PRAMOD (PHARMD)
Entity type:Individual
Prefix:
First Name:KETUR
Middle Name:PRAMOD
Last Name:DARJI
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1634 W POLK ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4352
Mailing Address - Country:US
Mailing Address - Phone:312-423-4200
Mailing Address - Fax:312-423-4392
Practice Address - Street 1:1634 W POLK ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4352
Practice Address - Country:US
Practice Address - Phone:312-423-4200
Practice Address - Fax:312-423-4392
Is Sole Proprietor?:No
Enumeration Date:2022-01-18
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.295993183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL051.295993OtherSTATE OF ILLINOIS LICENSE ID