Provider Demographics
NPI:1992301543
Name:LANG, KENNETH (RPH)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:LANG
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 1:19354 GALWAY BAY
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-7735
Mailing Address - Country:US
Mailing Address - Phone:708-296-8087
Mailing Address - Fax:
Practice Address - Street 1:221 SPRINGFIELD AVE
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-7653
Practice Address - Country:US
Practice Address - Phone:815-727-4722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-09
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051037043183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist