Provider Demographics
NPI:1902382195
Name:WESSEL, DANIEL JAY (RPH)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:JAY
Last Name:WESSEL
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 1:4125 AUTUMN LN
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-8639
Mailing Address - Country:US
Mailing Address - Phone:815-233-5860
Mailing Address - Fax:
Practice Address - Street 1:4860 HONONEGAH RD
Practice Address - Street 2:
Practice Address - City:ROSCOE
Practice Address - State:IL
Practice Address - Zip Code:61073-7777
Practice Address - Country:US
Practice Address - Phone:815-623-7798
Practice Address - Fax:815-623-9479
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-11
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051033107183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist