1740255421 NPI number — MRS. JENNIFER BOOTH HARDY PHARM.D.

Table of content: MRS. JENNIFER BOOTH HARDY PHARM.D. (NPI 1740255421)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740255421 NPI number — MRS. JENNIFER BOOTH HARDY PHARM.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HARDY
Provider First Name:
JENNIFER
Provider Middle Name:
BOOTH
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PHARM.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1740255421
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1316 POPLAR CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOMEWOOD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60430-4222
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-915-8453
Provider Business Mailing Address Fax Number:
708-915-8579

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19550 GOVERNORS HIGHWAY
Provider Second Line Business Practice Location Address:
SUITE 1100
Provider Business Practice Location Address City Name:
FLOSSMOOR
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60422
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-915-8453
Provider Business Practice Location Address Fax Number:
708-915-8579
Provider Enumeration Date:
02/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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