Provider Demographics
NPI:1902101033
Name:PALAZZOLO, DOMINIC PAUL (RPH)
Entity Type:Individual
Prefix:MR
First Name:DOMINIC
Middle Name:PAUL
Last Name:PALAZZOLO
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 1:1219 IVYWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-4392
Mailing Address - Country:US
Mailing Address - Phone:217-793-0992
Mailing Address - Fax:
Practice Address - Street 1:2305 W MONROE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-1438
Practice Address - Country:US
Practice Address - Phone:217-546-9558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-21
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051030072183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist