Provider Demographics
NPI:1609191279
Name:CHILAKURI, MADANA M
Entity type:Individual
Prefix:
First Name:MADANA
Middle Name:M
Last Name:CHILAKURI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2829 GLENARYE DR
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60046-7925
Mailing Address - Country:US
Mailing Address - Phone:207-756-4065
Mailing Address - Fax:
Practice Address - Street 1:1155 E PERSHING RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-4726
Practice Address - Country:US
Practice Address - Phone:217-877-2374
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-07
Last Update Date:2010-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.293017183500000X
WI14609-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist