Provider Demographics
NPI:1013299809
Name:TAYLOR, DOUGLAS EVERTON
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:EVERTON
Last Name:TAYLOR
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 1:1926 W HARRISON ST APT 209
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3717
Mailing Address - Country:US
Mailing Address - Phone:773-252-8346
Mailing Address - Fax:
Practice Address - Street 1:3320 W FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-2514
Practice Address - Country:US
Practice Address - Phone:773-252-8346
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-16
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051287539183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist