Healthcare Provider Details

I. General information

NPI: 1760875801
Provider Name (Legal Business Name): DOUGLAS GERWITZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2015
Last Update Date: 03/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5145 N CALIFORNIA AVE
CHICAGO IL
60625-3661
US

IV. Provider business mailing address

5145 N CALIFORNIA AVE
CHICAGO IL
60625-3661
US

V. Phone/Fax

Practice location:
  • Phone: 773-989-3810
  • Fax: 773-878-3829
Mailing address:
  • Phone: 773-989-3810
  • Fax: 773-878-3829

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051.291607
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number55881
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: