Provider Demographics
NPI:1780257527
Name:KNIGHTLY, BREANNE MARIE (RPH)
Entity type:Individual
Prefix:
First Name:BREANNE
Middle Name:MARIE
Last Name:KNIGHTLY
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10401 S CENTRAL PARK AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60655-3111
Mailing Address - Country:US
Mailing Address - Phone:773-633-5354
Mailing Address - Fax:
Practice Address - Street 1:17113 HARLEM AVE
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-3369
Practice Address - Country:US
Practice Address - Phone:708-532-7477
Practice Address - Fax:708-532-7391
Is Sole Proprietor?:No
Enumeration Date:2021-07-20
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.303980183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist