Provider Demographics
NPI:1336139146
Name:BOHANNON, CHAD ASA (RPH)
Entity Type:Individual
Prefix:MR
First Name:CHAD
Middle Name:ASA
Last Name:BOHANNON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:13637 N WILD SPRUCE LN
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:IL
Mailing Address - Zip Code:61523-9110
Mailing Address - Country:US
Mailing Address - Phone:309-579-3242
Mailing Address - Fax:309-274-8630
Practice Address - Street 1:318 S PLAZA PARK
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:IL
Practice Address - Zip Code:61523-2214
Practice Address - Country:US
Practice Address - Phone:309-274-9571
Practice Address - Fax:309-274-8630
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist