Provider Demographics
NPI:1760517718
Name:PROVENZANO, ANTHONY A (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:A
Last Name:PROVENZANO
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7222 BAYBERRY LN
Mailing Address - Street 2:
Mailing Address - City:DARIEN
Mailing Address - State:IL
Mailing Address - Zip Code:60561-3708
Mailing Address - Country:US
Mailing Address - Phone:630-663-0294
Mailing Address - Fax:
Practice Address - Street 1:3030 CULLERTON ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN PARK
Practice Address - State:IL
Practice Address - Zip Code:60131-2205
Practice Address - Country:US
Practice Address - Phone:847-916-4703
Practice Address - Fax:847-916-4114
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist