Provider Demographics
NPI:1730964404
Name:JOHN, ANGELA
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:JOHN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9032 W 140TH ST APT 3B
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-2136
Mailing Address - Country:US
Mailing Address - Phone:469-285-6288
Mailing Address - Fax:
Practice Address - Street 1:500 REMINGTON BLVD
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-4906
Practice Address - Country:US
Practice Address - Phone:630-856-3730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-30
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX65411183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No183500000XPharmacy Service ProvidersPharmacist