Provider Demographics
NPI:1194361048
Name:CARMODY, JOHN MARTIN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MARTIN
Last Name:CARMODY
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 1:2 NICHOLAS CT
Mailing Address - Street 2:
Mailing Address - City:WHITE HEATH
Mailing Address - State:IL
Mailing Address - Zip Code:61884-9342
Mailing Address - Country:US
Mailing Address - Phone:309-371-7862
Mailing Address - Fax:
Practice Address - Street 1:1 TROY SQ
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MO
Practice Address - Zip Code:63379-3101
Practice Address - Country:US
Practice Address - Phone:636-528-8667
Practice Address - Fax:636-462-7010
Is Sole Proprietor?:No
Enumeration Date:2019-11-25
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051029319183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist