Healthcare Provider Details

I. General information

NPI: 1154607133
Provider Name (Legal Business Name): MARTIN PAUL VACLAVEK RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2011
Last Update Date: 10/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6240 BELMONT RD
DOWNERS GROVE IL
60516-1638
US

IV. Provider business mailing address

6240 BELMONT RD
DOWNERS GROVE IL
60516-1638
US

V. Phone/Fax

Practice location:
  • Phone: 630-960-4160
  • Fax: 630-960-4651
Mailing address:
  • Phone: 630-960-4160
  • Fax: 630-960-4651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051034380
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: