Healthcare Provider Details

I. General information

NPI: 1205227493
Provider Name (Legal Business Name): MR. JUSTIN ANTHONY KUBERT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2015
Last Update Date: 02/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2939 W ADDISON ST
CHICAGO IL
60618-4635
US

IV. Provider business mailing address

2821 W ADDISON ST
CHICAGO IL
60618-4635
US

V. Phone/Fax

Practice location:
  • Phone: 773-604-7681
  • Fax:
Mailing address:
  • Phone: 773-604-7681
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number049.164002
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: