Provider Demographics
NPI:1043807423
Name:BHATTAL, IRVINPREET
Entity type:Individual
Prefix:
First Name:IRVINPREET
Middle Name:
Last Name:BHATTAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 W PETER LN
Mailing Address - Street 2:
Mailing Address - City:HAWTHORN WOODS
Mailing Address - State:IL
Mailing Address - Zip Code:60047-7512
Mailing Address - Country:US
Mailing Address - Phone:847-505-9930
Mailing Address - Fax:
Practice Address - Street 1:351 N EDWARDS BLVD
Practice Address - Street 2:
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-4563
Practice Address - Country:US
Practice Address - Phone:262-248-7885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-30
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19581875183500000X
IL051.302920183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist