Provider Demographics
NPI:1275915571
Name:IVY, HENRIETTA ANN
Entity Type:Individual
Prefix:MISS
First Name:HENRIETTA
Middle Name:ANN
Last Name:IVY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5575 CHAPEL HL
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-1082
Mailing Address - Country:US
Mailing Address - Phone:847-855-8106
Mailing Address - Fax:
Practice Address - Street 1:5575 CHAPEL HL
Practice Address - Street 2:
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-1082
Practice Address - Country:US
Practice Address - Phone:847-855-8106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-23
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051040617183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist