Provider Demographics
NPI:1598112104
Name:MODI, VIRAL
Entity Type:Individual
Prefix:
First Name:VIRAL
Middle Name:
Last Name:MODI
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 1:465 ROUTE 47
Mailing Address - Street 2:
Mailing Address - City:SUGAR GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60554-9402
Mailing Address - Country:US
Mailing Address - Phone:630-466-3769
Mailing Address - Fax:
Practice Address - Street 1:465 ROUTE 47
Practice Address - Street 2:
Practice Address - City:SUGAR GROVE
Practice Address - State:IL
Practice Address - Zip Code:60554-9402
Practice Address - Country:US
Practice Address - Phone:630-466-3769
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-24
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.289356183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist