Provider Demographics
NPI:1841776069
Name:NORONHA, NATASHA SAVINA
Entity Type:Individual
Prefix:
First Name:NATASHA
Middle Name:SAVINA
Last Name:NORONHA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4902 SMITH DR
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-5806
Mailing Address - Country:US
Mailing Address - Phone:734-502-1895
Mailing Address - Fax:
Practice Address - Street 1:501 BELT LINE RD
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62234-4410
Practice Address - Country:US
Practice Address - Phone:618-345-7811
Practice Address - Fax:618-345-7812
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-11
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.291700183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty