Provider Demographics
NPI:1710585575
Name:CISNEROS, TARA ARKAN (RPH)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:ARKAN
Last Name:CISNEROS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:ARKAN
Other - Last Name:JEBRAEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8034 W LYONS ST
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:IL
Mailing Address - Zip Code:60714-1332
Mailing Address - Country:US
Mailing Address - Phone:847-293-8669
Mailing Address - Fax:
Practice Address - Street 1:9000 N GREENWOOD AVE
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:IL
Practice Address - Zip Code:60714-1408
Practice Address - Country:US
Practice Address - Phone:847-298-3050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-14
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.303450183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist