Provider Demographics
NPI:1992316046
Name:HOME, JIM
Entity type:Individual
Prefix:
First Name:JIM
Middle Name:
Last Name:HOME
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 1:296 E DEERPATH
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-1940
Mailing Address - Country:US
Mailing Address - Phone:847-234-2413
Mailing Address - Fax:847-234-7921
Practice Address - Street 1:296 E DEERPATH
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-1940
Practice Address - Country:US
Practice Address - Phone:847-234-2413
Practice Address - Fax:847-234-7921
Is Sole Proprietor?:No
Enumeration Date:2020-08-12
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051299848183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist