Provider Demographics
NPI:1902119282
Name:ITTEERA, REGINA (PHARMD)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:ITTEERA
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10900 S DOTY AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628-3804
Mailing Address - Country:US
Mailing Address - Phone:773-468-0721
Mailing Address - Fax:773-468-0724
Practice Address - Street 1:10900 S DOTY AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628-3804
Practice Address - Country:US
Practice Address - Phone:773-468-0721
Practice Address - Fax:773-468-0724
Is Sole Proprietor?:No
Enumeration Date:2010-07-15
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA21264183500000X
IL0512948141835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL051294814OtherSTATE LICENSE NUMBER