Provider Demographics
NPI:1952688111
Name:LIVINGSTON, TIRRELL ANTOINE
Entity Type:Individual
Prefix:MR
First Name:TIRRELL
Middle Name:ANTOINE
Last Name:LIVINGSTON
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 1:7848 S SAGINAW AVE
Mailing Address - Street 2:APT. 1A
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60649-5279
Mailing Address - Country:US
Mailing Address - Phone:773-663-8570
Mailing Address - Fax:
Practice Address - Street 1:7544 S STONY ISLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60649-3926
Practice Address - Country:US
Practice Address - Phone:773-667-6959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-15
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL049.188507183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician