Provider Demographics
NPI:1588269559
Name:VARGHESE, TITY
Entity type:Individual
Prefix:
First Name:TITY
Middle Name:
Last Name:VARGHESE
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 1:1008 W GARFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:BARTONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61607-1851
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1008 W GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:BARTONVILLE
Practice Address - State:IL
Practice Address - Zip Code:61607-1851
Practice Address - Country:US
Practice Address - Phone:309-697-8122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051286247183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist