Provider Demographics
NPI:1346650207
Name:KOENEN, ELIZABETH
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:KOENEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:531 MAYBORNE LN
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-5001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:855 S RANDALL RD
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-1570
Practice Address - Country:US
Practice Address - Phone:630-762-7210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-30
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.288625183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist