Provider Demographics
NPI:1639450323
Name:DALTON, ELLEN LISA (RPH)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:LISA
Last Name:DALTON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:236 S OAK ST
Mailing Address - Street 2:
Mailing Address - City:ITASCA
Mailing Address - State:IL
Mailing Address - Zip Code:60143-2052
Mailing Address - Country:US
Mailing Address - Phone:630-250-8750
Mailing Address - Fax:
Practice Address - Street 1:1701 E KENSINGTON RD
Practice Address - Street 2:
Practice Address - City:MT PROSPECT
Practice Address - State:IL
Practice Address - Zip Code:60056-1922
Practice Address - Country:US
Practice Address - Phone:847-635-9962
Practice Address - Fax:847-635-9981
Is Sole Proprietor?:No
Enumeration Date:2011-09-08
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051035992183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist