Provider Demographics
NPI:1346632718
Name:NIETO, JOSEPH EDGAR (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:EDGAR
Last Name:NIETO
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3303 W 26TH ST STE 101
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60623-4036
Mailing Address - Country:US
Mailing Address - Phone:773-521-1718
Mailing Address - Fax:773-521-4052
Practice Address - Street 1:3303 W 26TH ST STE 101
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623-4036
Practice Address - Country:US
Practice Address - Phone:773-521-1718
Practice Address - Fax:773-521-4052
Is Sole Proprietor?:No
Enumeration Date:2015-02-23
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.295894183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist