Healthcare Provider Details

I. General information

NPI: 1215384763
Provider Name (Legal Business Name): THEODORE HUPAC SR. BSPHARM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: THEODORE HUPAC SR. BSPHARM

II. Dates (important events)

Enumeration Date: 05/14/2016
Last Update Date: 05/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9534 S ROBERTS RD
HICKORY HILLS IL
60457-2239
US

IV. Provider business mailing address

9534 S ROBERTS RD
HICKORY HILLS IL
60457-2239
US

V. Phone/Fax

Practice location:
  • Phone: 708-598-0500
  • Fax: 708-598-8684
Mailing address:
  • Phone: 708-598-0564
  • Fax: 708-598-8684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051-034542
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: