Healthcare Provider Details

I. General information

NPI: 1063493419
Provider Name (Legal Business Name): TIMOTHY JOHN NOVAK RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 WILMOT RD
DEERFIELD IL
60015-4619
US

IV. Provider business mailing address

9101 FRANCES LN
ORLAND PARK IL
60462-4745
US

V. Phone/Fax

Practice location:
  • Phone: 708-795-9030
  • Fax:
Mailing address:
  • Phone: 708-349-6576
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: