Provider Demographics
NPI:1932500147
Name:D'AVERSA, ALEXANDER (PHARMD)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:D'AVERSA
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:466 NELSON RD
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-2946
Mailing Address - Country:US
Mailing Address - Phone:815-485-2735
Mailing Address - Fax:
Practice Address - Street 1:466 NELSON RD
Practice Address - Street 2:
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-2946
Practice Address - Country:US
Practice Address - Phone:815-485-2735
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-07
Last Update Date:2014-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.297919183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist