Healthcare Provider Details

I. General information

NPI: 1194688416
Provider Name (Legal Business Name): SIRIWAN KOPRACH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2025
Last Update Date: 12/04/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4035 N SAWYER AVE
CHICAGO IL
60618-3303
US

IV. Provider business mailing address

4035 N SAWYER AVE
CHICAGO IL
60618-3303
US

V. Phone/Fax

Practice location:
  • Phone: 773-747-1610
  • Fax:
Mailing address:
  • Phone: 773-747-1610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number049.321176
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: