Provider Demographics
NPI:1467891697
Name:ALLGOOD, THERESA KATHLEEN (BS)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:KATHLEEN
Last Name:ALLGOOD
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3023 S CREEK POINTE LN
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-7186
Mailing Address - Country:US
Mailing Address - Phone:847-736-3490
Mailing Address - Fax:208-272-9449
Practice Address - Street 1:210 N HIGHBROOK WAY
Practice Address - Street 2:
Practice Address - City:STAR
Practice Address - State:ID
Practice Address - Zip Code:83669-6219
Practice Address - Country:US
Practice Address - Phone:208-272-9450
Practice Address - Fax:208-272-9449
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-20
Last Update Date:2024-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.288300183500000X
IDP8284183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist