Provider Demographics
NPI:1982051769
Name:TRITTHARDT, JOSEPH ADAM
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:ADAM
Last Name:TRITTHARDT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:485 ELA RD
Mailing Address - Street 2:
Mailing Address - City:LAKE ZURICH
Mailing Address - State:IL
Mailing Address - Zip Code:60047-2367
Mailing Address - Country:US
Mailing Address - Phone:847-540-0130
Mailing Address - Fax:
Practice Address - Street 1:206 N GRAND AVE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:TX
Practice Address - Zip Code:76240-4320
Practice Address - Country:US
Practice Address - Phone:940-665-7622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-20
Last Update Date:2024-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX63839183500000X
IL051292990183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist