Provider Demographics
NPI:1225311707
Name:CONWAY, CASEY R
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:R
Last Name:CONWAY
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 1:100 W LINCOLN HWY
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-3678
Mailing Address - Country:US
Mailing Address - Phone:815-756-1815
Mailing Address - Fax:815-748-5527
Practice Address - Street 1:100 W LINCOLN HWY
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-3678
Practice Address - Country:US
Practice Address - Phone:815-756-1815
Practice Address - Fax:815-748-5527
Is Sole Proprietor?:No
Enumeration Date:2011-09-21
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.292355183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist