Provider Demographics
NPI:1295850600
Name:SERGO, JOAN (RPH)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:
Last Name:SERGO
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8501 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60513-1705
Mailing Address - Country:US
Mailing Address - Phone:708-387-7124
Mailing Address - Fax:
Practice Address - Street 1:259 LAKE ST
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-2636
Practice Address - Country:US
Practice Address - Phone:708-525-1736
Practice Address - Fax:708-383-9172
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist