Provider Demographics
NPI:1912500125
Name:GIUSTINO, DOMENICO
Entity Type:Individual
Prefix:MR
First Name:DOMENICO
Middle Name:
Last Name:GIUSTINO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:DOMENICO
Other - Middle Name:
Other - Last Name:GIUSTINO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:8507 BROOKSIDE GLEN DR
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60487-7044
Mailing Address - Country:US
Mailing Address - Phone:815-325-5441
Mailing Address - Fax:
Practice Address - Street 1:245 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:COAL CITY
Practice Address - State:IL
Practice Address - Zip Code:60416-1534
Practice Address - Country:US
Practice Address - Phone:815-634-0599
Practice Address - Fax:815-634-0686
Is Sole Proprietor?:No
Enumeration Date:2020-11-19
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-040229183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist