Provider Demographics
NPI:1154089761
Name:DUFOE, NATHAN
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:DUFOE
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 1:4843 BLUESTEM RD
Mailing Address - Street 2:
Mailing Address - City:ROSCOE
Mailing Address - State:IL
Mailing Address - Zip Code:61073-7794
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4843 BLUESTEM RD
Practice Address - Street 2:
Practice Address - City:ROSCOE
Practice Address - State:IL
Practice Address - Zip Code:61073-7794
Practice Address - Country:US
Practice Address - Phone:815-623-1696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-01
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.304444183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist