Provider Demographics
NPI:1861003840
Name:HERATY, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:HERATY
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 1:1801 INGALLS AVE
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-7903
Mailing Address - Country:US
Mailing Address - Phone:815-729-1680
Mailing Address - Fax:
Practice Address - Street 1:1801 INGALLS AVE
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-7903
Practice Address - Country:US
Practice Address - Phone:815-729-1680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-12
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051298573183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist