Provider Demographics
NPI:1003193962
Name:BARDAHL, GEORGE (RPH)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:
Last Name:BARDAHL
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18461 DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:HOMEWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60430-3229
Mailing Address - Country:US
Mailing Address - Phone:708-957-1640
Mailing Address - Fax:
Practice Address - Street 1:18461 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:HOMEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60430-3229
Practice Address - Country:US
Practice Address - Phone:708-957-1640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-07
Last Update Date:2011-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.040626183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist