Provider Demographics
NPI:1447537147
Name:KWON, LYNDELLE
Entity type:Individual
Prefix:
First Name:LYNDELLE
Middle Name:
Last Name:KWON
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 1:2379 PLAINFIELD RD
Mailing Address - Street 2:
Mailing Address - City:CREST HILL
Mailing Address - State:IL
Mailing Address - Zip Code:60403-1848
Mailing Address - Country:US
Mailing Address - Phone:815-730-8663
Mailing Address - Fax:815-730-8677
Practice Address - Street 1:2379 PLAINFIELD RD
Practice Address - Street 2:
Practice Address - City:CREST HILL
Practice Address - State:IL
Practice Address - Zip Code:60403-1848
Practice Address - Country:US
Practice Address - Phone:815-730-8663
Practice Address - Fax:815-730-8677
Is Sole Proprietor?:No
Enumeration Date:2011-11-08
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051290542183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist