Provider Demographics
NPI:1083995732
Name:HANNON, GARY R (RPH)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:R
Last Name:HANNON
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 1:1400 E LAKE COOK RD
Mailing Address - Street 2:SUITE 125
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-8217
Mailing Address - Country:US
Mailing Address - Phone:847-676-5365
Mailing Address - Fax:224-676-5365
Practice Address - Street 1:1400 E LAKE COOK RD
Practice Address - Street 2:SUITE 125
Practice Address - City:BUFFALO GROVE
Practice Address - State:IL
Practice Address - Zip Code:60089-8217
Practice Address - Country:US
Practice Address - Phone:847-676-5365
Practice Address - Fax:224-676-5365
Is Sole Proprietor?:No
Enumeration Date:2011-09-07
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.034902183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist