Provider Demographics
NPI:1912278979
Name:MONROE, TEXAS JACK (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:TEXAS
Middle Name:JACK
Last Name:MONROE
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:T
Other - Middle Name:JACK
Other - Last Name:MONROE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:40755 N KILBOURNE RD
Mailing Address - Street 2:
Mailing Address - City:WADSWORTH
Mailing Address - State:IL
Mailing Address - Zip Code:60083-9749
Mailing Address - Country:US
Mailing Address - Phone:847-662-7356
Mailing Address - Fax:
Practice Address - Street 1:1160 W LAKE COOK RD
Practice Address - Street 2:
Practice Address - City:BUFFALO GROVE
Practice Address - State:IL
Practice Address - Zip Code:60089-1979
Practice Address - Country:US
Practice Address - Phone:847-537-4074
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-23
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-030542183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist