Provider Demographics
NPI:1346833407
Name:MCKINLEY, QUINTET NYESSIE (CPHT)
Entity Type:Individual
Prefix:
First Name:QUINTET
Middle Name:NYESSIE
Last Name:MCKINLEY
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:QUINTET
Other - Middle Name:
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:16820 TRAPET AVE
Mailing Address - Street 2:
Mailing Address - City:HAZEL CREST
Mailing Address - State:IL
Mailing Address - Zip Code:60429-1318
Mailing Address - Country:US
Mailing Address - Phone:708-803-1126
Mailing Address - Fax:
Practice Address - Street 1:12290 S PULASKI RD
Practice Address - Street 2:
Practice Address - City:ALSIP
Practice Address - State:IL
Practice Address - Zip Code:60803-1405
Practice Address - Country:US
Practice Address - Phone:708-385-2006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-18
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0492439073336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy