Healthcare Provider Details

I. General information

NPI: 1265544100
Provider Name (Legal Business Name): KOZ-LAZ INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 10/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6456 W ARCHER AVE
CHICAGO IL
60638-2537
US

IV. Provider business mailing address

6456 W ARCHER AVE
CHICAGO IL
60638-2537
US

V. Phone/Fax

Practice location:
  • Phone: 773-586-1134
  • Fax: 773-586-1151
Mailing address:
  • Phone: 773-586-1134
  • Fax: 773-586-1151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number054013977
License Number StateIL

VIII. Authorized Official

Name: JACK LAZZARA
Title or Position: PRESIDENT AND OWNER
Credential: RPH
Phone: 773-586-1134