Healthcare Provider Details

I. General information

NPI: 1003435926
Provider Name (Legal Business Name): KYLE CORSO MORK PHARMD, MBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2020
Last Update Date: 04/10/2020
Certification Date: 04/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 S WOOD ST
CHICAGO IL
60612-4325
US

IV. Provider business mailing address

163 NORTHGATE RD
RIVERSIDE IL
60546-1683
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-6783
  • Fax: 312-996-8525
Mailing address:
  • Phone: 630-464-5349
  • Fax: 312-996-8525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License Number049168241
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: