Provider Demographics
NPI:1043811151
Name:PATEL, PALAK S (RPH)
Entity Type:Individual
Prefix:
First Name:PALAK
Middle Name:S
Last Name:PATEL
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10409 N TRAILS EDGE DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-8833
Mailing Address - Country:US
Mailing Address - Phone:847-873-7672
Mailing Address - Fax:
Practice Address - Street 1:8915 N ALLEN RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-1534
Practice Address - Country:US
Practice Address - Phone:309-693-9854
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-04
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.290868183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist