Provider Demographics
NPI:1972199115
Name:KEANE, PATCHARAPORN (PHARMD)
Entity Type:Individual
Prefix:
First Name:PATCHARAPORN
Middle Name:
Last Name:KEANE
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 1:4902 N MAGNOLIA AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-7546
Mailing Address - Country:US
Mailing Address - Phone:630-888-2551
Mailing Address - Fax:
Practice Address - Street 1:1004 SHOOTING PARK RD
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IL
Practice Address - Zip Code:61354-1871
Practice Address - Country:US
Practice Address - Phone:815-224-1411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-11
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.296468183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist