Healthcare Provider Details

I. General information

NPI: 1164021614
Provider Name (Legal Business Name): LEANNA GRYZ PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2020
Last Update Date: 10/25/2020
Certification Date: 10/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5501 S HALSTED ST STE 147
CHICAGO IL
60621-2229
US

IV. Provider business mailing address

11111 S KEAN AVE APT 101
PALOS HILLS IL
60465-3106
US

V. Phone/Fax

Practice location:
  • Phone: 773-359-8570
  • Fax: 773-359-8571
Mailing address:
  • Phone: 708-897-4102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051289192
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: