Provider Demographics
NPI:1124569173
Name:DOHERTY, TOBIAS (PHARMD)
Entity type:Individual
Prefix:DR
First Name:TOBIAS
Middle Name:
Last Name:DOHERTY
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1146 WINDBROOKE DR APT 202
Mailing Address - Street 2:
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-2317
Mailing Address - Country:US
Mailing Address - Phone:636-734-4007
Mailing Address - Fax:
Practice Address - Street 1:7701 GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-4043
Practice Address - Country:US
Practice Address - Phone:262-612-1610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-09
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051300106183500000X
WI1873940183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist