Provider Demographics
NPI:1427822360
Name:COSTIS, JAN (RPH)
Entity type:Individual
Prefix:
First Name:JAN
Middle Name:
Last Name:COSTIS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2045 PLUM GROVE RD
Mailing Address - Street 2:
Mailing Address - City:ROLLING MEADOWS
Mailing Address - State:IL
Mailing Address - Zip Code:60008-1992
Mailing Address - Country:US
Mailing Address - Phone:847-303-2451
Mailing Address - Fax:
Practice Address - Street 1:16 BRANDYWINE RD
Practice Address - Street 2:
Practice Address - City:SOUTH BARRINGTON
Practice Address - State:IL
Practice Address - Zip Code:60010-9311
Practice Address - Country:US
Practice Address - Phone:847-567-6100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-10
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051034058183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist