Healthcare Provider Details

I. General information

NPI: 1801125547
Provider Name (Legal Business Name): ROBERTA HUNTER ZICCARELLI MS, RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2009
Last Update Date: 12/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8700 W BRYN MAWR AVE STE 700N
CHICAGO IL
60631-3509
US

IV. Provider business mailing address

1725 TALLGRASS LN
LAKE FOREST IL
60045-4858
US

V. Phone/Fax

Practice location:
  • Phone: 773-632-1685
  • Fax:
Mailing address:
  • Phone: 847-773-6321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number051-036405
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: