Provider Demographics
NPI:1952688053
Name:SWANSON, KEVIN C (PHARM D)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:C
Last Name:SWANSON
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 N STONE AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60526-1440
Mailing Address - Country:US
Mailing Address - Phone:708-469-7303
Mailing Address - Fax:
Practice Address - Street 1:3405 S M L KING DR
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-4108
Practice Address - Country:US
Practice Address - Phone:312-326-4058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-03
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.291375183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist