Provider Demographics
NPI:1558983825
Name:WALSH, DOMENICA BENINA
Entity Type:Individual
Prefix:
First Name:DOMENICA
Middle Name:BENINA
Last Name:WALSH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 NELSON RD
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-2944
Mailing Address - Country:US
Mailing Address - Phone:815-462-1998
Mailing Address - Fax:
Practice Address - Street 1:475 NELSON RD
Practice Address - Street 2:
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-2944
Practice Address - Country:US
Practice Address - Phone:815-462-1998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-10
Last Update Date:2020-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL049.198980183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist