Provider Demographics
NPI:1306204243
Name:HERNANDEZ, OMAR DAVID (PHARMD)
Entity Type:Individual
Prefix:
First Name:OMAR
Middle Name:DAVID
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4913 HAMPSHIRE LN
Mailing Address - Street 2:
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60051-8545
Mailing Address - Country:US
Mailing Address - Phone:765-491-3164
Mailing Address - Fax:
Practice Address - Street 1:4201 W MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-8409
Practice Address - Country:US
Practice Address - Phone:815-759-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-07
Last Update Date:2016-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.298000183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist