Provider Demographics
NPI:1376759555
Name:SHOSTAK, ALLA (RPH)
Entity Type:Individual
Prefix:
First Name:ALLA
Middle Name:
Last Name:SHOSTAK
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1823 APPLE VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:WAUCONDA
Mailing Address - State:IL
Mailing Address - Zip Code:60084-1420
Mailing Address - Country:US
Mailing Address - Phone:847-487-7445
Mailing Address - Fax:
Practice Address - Street 1:1042 S ELMHURST RD
Practice Address - Street 2:
Practice Address - City:MOUNT PROSPECT
Practice Address - State:IL
Practice Address - Zip Code:60056-4240
Practice Address - Country:US
Practice Address - Phone:847-956-0070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist