Provider Demographics
NPI:1427405802
Name:COLLETTI, JEROME N
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:N
Last Name:COLLETTI
Suffix:
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 1:481 BUSSE HWY
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-3252
Mailing Address - Country:US
Mailing Address - Phone:847-696-4315
Mailing Address - Fax:847-696-0411
Practice Address - Street 1:481 BUSSE HWY
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-3252
Practice Address - Country:US
Practice Address - Phone:847-696-4315
Practice Address - Fax:847-696-0411
Is Sole Proprietor?:No
Enumeration Date:2016-05-16
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.034929183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist