Provider Demographics
NPI:1043714157
Name:GRIBBLE, DO'MONIQUE LA'CHELLE (PHARMD)
Entity type:Individual
Prefix:DR
First Name:DO'MONIQUE
Middle Name:LA'CHELLE
Last Name:GRIBBLE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30023 N WAUKEGAN RD APT 104
Mailing Address - Street 2:
Mailing Address - City:LAKE BLUFF
Mailing Address - State:IL
Mailing Address - Zip Code:60044-1083
Mailing Address - Country:US
Mailing Address - Phone:313-268-0442
Mailing Address - Fax:
Practice Address - Street 1:30023 N WAUKEGAN RD APT 104
Practice Address - Street 2:
Practice Address - City:LAKE BLUFF
Practice Address - State:IL
Practice Address - Zip Code:60044-1083
Practice Address - Country:US
Practice Address - Phone:313-268-0442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-22
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18237-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist