Healthcare Provider Details

I. General information

NPI: 1568303378
Provider Name (Legal Business Name): BENJAMIN WYATT CASTRO-MATTHEWS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2026
Last Update Date: 04/03/2026
Certification Date: 04/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3033 N BROADWAY ST
CHICAGO IL
60657-5315
US

IV. Provider business mailing address

3526 N PINE GROVE AVE
CHICAGO IL
60657-1877
US

V. Phone/Fax

Practice location:
  • Phone: 773-883-6141
  • Fax: 773-883-6146
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number049318126
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: