Provider Demographics
NPI:1235217662
Name:DONNELLY, EDWARD BRIAN (RPH)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:BRIAN
Last Name:DONNELLY
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 1:1700 MONMOUTH PL
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60516-3119
Mailing Address - Country:US
Mailing Address - Phone:630-971-8632
Mailing Address - Fax:
Practice Address - Street 1:2929 S ELLIS AVE
Practice Address - Street 2:ROTHSCHILD BASEMENT
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-3395
Practice Address - Country:US
Practice Address - Phone:312-791-3334
Practice Address - Fax:312-791-3391
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist