Provider Demographics
NPI:1942582523
Name:GARDNER, AYANNA NKECHI (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:AYANNA
Middle Name:NKECHI
Last Name:GARDNER
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16707 KIMBARK CT
Mailing Address - Street 2:
Mailing Address - City:SOUTH HOLLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60473-3243
Mailing Address - Country:US
Mailing Address - Phone:708-646-5284
Mailing Address - Fax:
Practice Address - Street 1:20950 GOVERNORS HWY
Practice Address - Street 2:
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1039
Practice Address - Country:US
Practice Address - Phone:708-747-0121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-09
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051292144183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist