Provider Demographics
NPI:1912472259
Name:FOUNTAS, IOANNIS KYRIAKOS (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:IOANNIS
Middle Name:KYRIAKOS
Last Name:FOUNTAS
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:370 WOODBINE DR
Mailing Address - Street 2:
Mailing Address - City:WOOD DALE
Mailing Address - State:IL
Mailing Address - Zip Code:60191-2524
Mailing Address - Country:US
Mailing Address - Phone:630-616-0084
Mailing Address - Fax:
Practice Address - Street 1:1340 S CANAL ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-5208
Practice Address - Country:US
Practice Address - Phone:312-666-5612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-12
Last Update Date:2018-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.301641183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist