Provider Demographics
NPI:1346642725
Name:ENRIQUEZ, GERALD G (PHARMD)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:G
Last Name:ENRIQUEZ
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 1:695 W BOUGHTON RD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-1752
Mailing Address - Country:US
Mailing Address - Phone:630-771-1494
Mailing Address - Fax:630-771-1542
Practice Address - Street 1:695 W BOUGHTON RD
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-1752
Practice Address - Country:US
Practice Address - Phone:630-771-1494
Practice Address - Fax:630-771-1542
Is Sole Proprietor?:No
Enumeration Date:2014-09-17
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.297989183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist