Provider Demographics
NPI:1962888461
Name:COSTELLO, KEVIN (RPH)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 E RANDOLPH ST
Mailing Address - Street 2:2517
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-7329
Mailing Address - Country:US
Mailing Address - Phone:708-250-8097
Mailing Address - Fax:
Practice Address - Street 1:151 N STATE ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60601-3601
Practice Address - Country:US
Practice Address - Phone:312-863-4249
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-06
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051035403183500000X
HIPH2780183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist