Provider Demographics
NPI:1487850095
Name:BRYANT, CALVIN LEE JR (PHARMACIST)
Entity Type:Individual
Prefix:MR
First Name:CALVIN
Middle Name:LEE
Last Name:BRYANT
Suffix:JR
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10724 S DREW ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-3424
Mailing Address - Country:US
Mailing Address - Phone:773-266-1116
Mailing Address - Fax:
Practice Address - Street 1:10724 S DREW ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-3424
Practice Address - Country:US
Practice Address - Phone:773-266-1116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-22
Last Update Date:2008-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051034870183500000X, 1835P1200X, 1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL051034870OtherPHARMACIST LICENSE #