Provider Demographics
NPI:1295002970
Name:ETIM, ITORO
Entity Type:Individual
Prefix:
First Name:ITORO
Middle Name:
Last Name:ETIM
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 1:1900 W JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-2202
Mailing Address - Country:US
Mailing Address - Phone:217-787-0648
Mailing Address - Fax:
Practice Address - Street 1:1900 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-2202
Practice Address - Country:US
Practice Address - Phone:217-787-0648
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-22
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051292982183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist