Provider Demographics
NPI:1609230978
Name:ANDRADE, DONALD
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:
Last Name:ANDRADE
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 1:1150 W CARL SANDBURG DR
Mailing Address - Street 2:
Mailing Address - City:GALESBURG
Mailing Address - State:IL
Mailing Address - Zip Code:61401-1387
Mailing Address - Country:US
Mailing Address - Phone:309-344-3088
Mailing Address - Fax:309-344-3154
Practice Address - Street 1:1150 W CARL SANDBURG DR
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-1387
Practice Address - Country:US
Practice Address - Phone:309-344-3088
Practice Address - Fax:309-344-3154
Is Sole Proprietor?:No
Enumeration Date:2016-04-12
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-039135183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1801827969OtherNPI