Provider Demographics
NPI:1700402203
Name:BANUELOS, EDIAN
Entity Type:Individual
Prefix:
First Name:EDIAN
Middle Name:
Last Name:BANUELOS
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 1:365 LAKE MARIAN RD
Mailing Address - Street 2:
Mailing Address - City:CARPENTERSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60110-2096
Mailing Address - Country:US
Mailing Address - Phone:847-426-4272
Mailing Address - Fax:
Practice Address - Street 1:365 LAKE MARIAN RD
Practice Address - Street 2:
Practice Address - City:CARPENTERSVILLE
Practice Address - State:IL
Practice Address - Zip Code:60110-2096
Practice Address - Country:US
Practice Address - Phone:847-426-4272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-19
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.303055183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL051.303055OtherIDFPR