Provider Demographics
NPI:1275814691
Name:NANOS, MICHAEL NICHOLAS (RPH)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:NICHOLAS
Last Name:NANOS
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 1:16 TOURNAMENT DR N
Mailing Address - Street 2:
Mailing Address - City:HAWTHORN WOODS
Mailing Address - State:IL
Mailing Address - Zip Code:60047-8401
Mailing Address - Country:US
Mailing Address - Phone:847-865-5283
Mailing Address - Fax:
Practice Address - Street 1:701 S MIDLOTHIAN RD
Practice Address - Street 2:
Practice Address - City:MUNDELEIN
Practice Address - State:IL
Practice Address - Zip Code:60060-2686
Practice Address - Country:US
Practice Address - Phone:847-949-7198
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-30
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051040646183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist