Provider Demographics
NPI:1235718792
Name:KAVANAUGH, JAMES MICHAEL (RPH)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:MICHAEL
Last Name:KAVANAUGH
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 1:372 YORKSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:MUNDELEIN
Mailing Address - State:IL
Mailing Address - Zip Code:60060-4512
Mailing Address - Country:US
Mailing Address - Phone:847-648-2631
Mailing Address - Fax:
Practice Address - Street 1:404 N SEYMOUR AVE
Practice Address - Street 2:
Practice Address - City:MUNDELEIN
Practice Address - State:IL
Practice Address - Zip Code:60060-1835
Practice Address - Country:US
Practice Address - Phone:224-475-0020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-02
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-035432183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL051-035432OtherPHARMACY LICENSE