Provider Demographics
NPI:1124309596
Name:GAINES, CHARLES WESLEY (PHARM D)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:WESLEY
Last Name:GAINES
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17955 WOLF RD
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60467-9427
Mailing Address - Country:US
Mailing Address - Phone:708-478-3758
Mailing Address - Fax:708-478-3753
Practice Address - Street 1:17955 WOLF RD
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60467-9427
Practice Address - Country:US
Practice Address - Phone:708-478-3758
Practice Address - Fax:708-478-3753
Is Sole Proprietor?:No
Enumeration Date:2011-08-30
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051289352183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist