Provider Demographics
NPI:1033520705
Name:LELLISH, DONALD
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:
Last Name:LELLISH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1908 DAKOTA RDG
Mailing Address - Street 2:
Mailing Address - City:JOHNSBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60051-5285
Mailing Address - Country:US
Mailing Address - Phone:815-344-6647
Mailing Address - Fax:
Practice Address - Street 1:815 N. RANDALL RD
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123
Practice Address - Country:US
Practice Address - Phone:847-717-6510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-15
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0510322891835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy