Provider Demographics
NPI:1689062424
Name:PAK, ALEXANDER
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:PAK
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 1:220 S CENTURY BLVD
Mailing Address - Street 2:
Mailing Address - City:RANTOUL
Mailing Address - State:IL
Mailing Address - Zip Code:61866-2309
Mailing Address - Country:US
Mailing Address - Phone:217-892-8175
Mailing Address - Fax:217-892-8702
Practice Address - Street 1:220 S CENTURY BLVD
Practice Address - Street 2:
Practice Address - City:RANTOUL
Practice Address - State:IL
Practice Address - Zip Code:61866-2309
Practice Address - Country:US
Practice Address - Phone:217-892-8175
Practice Address - Fax:217-892-8702
Is Sole Proprietor?:No
Enumeration Date:2015-01-01
Last Update Date:2015-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.298286183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist