MEDICARE: MR. EDMUND VINCENT MIRECKI RPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist		IL

General Provider Information

NPI Number	:	1982716601
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. EDMUND VINCENT MIRECKI RPH

Provider Business Mailing Address
First Line	:	161 N PARK RD
Second Line	:
City	:	LA GRANGE
State	:	IL
Zip	:	60525-1854
Country	:	US
Telephone Number	:	708-354-4335
Fax Number	:	773-579-0427

Provider Business Practice Location Address
First Line	:	4710 S WESTERN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60609-4060
Country	:	US
Telephone Number	:	773-579-0366
Fax Number	:	773-579-0427

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	07/08/2007

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