Healthcare Provider Details

I. General information

NPI: 1710507025
Provider Name (Legal Business Name): PETER WU PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2020
Last Update Date: 04/16/2020
Certification Date: 04/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 W HARRISON ST
CHICAGO IL
60612-3841
US

IV. Provider business mailing address

1965 S WELLS ST
CHICAGO IL
60616-4356
US

V. Phone/Fax

Practice location:
  • Phone: 312-563-2363
  • Fax:
Mailing address:
  • Phone: 312-804-0856
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835X0200X
TaxonomyOncology Pharmacist
License Number051300417
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: