Provider Demographics
NPI:1366000275
Name:VALDEPENAS, JOHN BENITO TALUSAN IV
Entity Type:Individual
Prefix:DR
First Name:JOHN BENITO
Middle Name:TALUSAN
Last Name:VALDEPENAS
Suffix:IV
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3925 W ELM ST
Mailing Address - Street 2:
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050-4361
Mailing Address - Country:US
Mailing Address - Phone:815-363-0722
Mailing Address - Fax:
Practice Address - Street 1:3925 W ELM ST
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-4361
Practice Address - Country:US
Practice Address - Phone:815-363-0722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-05
Last Update Date:2019-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.301854183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist