Provider Demographics
NPI:1164705414
Name:FRY, JONATHAN (PHARMD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:FRY
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 AXLINE RD
Mailing Address - Street 2:
Mailing Address - City:CHATHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62629-1574
Mailing Address - Country:US
Mailing Address - Phone:630-873-5922
Mailing Address - Fax:
Practice Address - Street 1:2140 N PEORIA RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-1840
Practice Address - Country:US
Practice Address - Phone:217-544-2925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-22
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051292483183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist