Provider Demographics
NPI:1205589181
Name:QUINONES, DONALD
Entity type:Individual
Prefix:MR
First Name:DONALD
Middle Name:
Last Name:QUINONES
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 1:201 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HAVANA
Mailing Address - State:IL
Mailing Address - Zip Code:62644-1198
Mailing Address - Country:US
Mailing Address - Phone:309-543-2253
Mailing Address - Fax:309-543-3471
Practice Address - Street 1:201 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HAVANA
Practice Address - State:IL
Practice Address - Zip Code:62644-1198
Practice Address - Country:US
Practice Address - Phone:309-543-2253
Practice Address - Fax:309-543-3471
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-31
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051036650183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL371311057001Medicaid