Provider Demographics
NPI:1851041628
Name:PERUMBEL JOHN, CHINCHU
Entity Type:Individual
Prefix:
First Name:CHINCHU
Middle Name:
Last Name:PERUMBEL JOHN
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 1:4330 N MEADE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60634-1522
Mailing Address - Country:US
Mailing Address - Phone:224-415-5584
Mailing Address - Fax:
Practice Address - Street 1:4748 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639-4640
Practice Address - Country:US
Practice Address - Phone:773-745-6642
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-25
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.304572183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist