Provider Demographics
NPI:1508312166
Name:AIROLA, DALE (RPH)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:
Last Name:AIROLA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17033 BURTON AVE
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:IL
Mailing Address - Zip Code:60441-4607
Mailing Address - Country:US
Mailing Address - Phone:708-285-3253
Mailing Address - Fax:
Practice Address - Street 1:17033 BURTON AVE
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:IL
Practice Address - Zip Code:60441-4607
Practice Address - Country:US
Practice Address - Phone:708-285-3253
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051029129183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL051029129OtherSTATE LICENCE NUMBER