Healthcare Provider Details

I. General information

NPI: 1619076718
Provider Name (Legal Business Name): KRYSTYNA A WYTANIEC RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5TH AVE & ROOSEVELT RD
HINES IL
60141
US

IV. Provider business mailing address

1434 LAVERNE AVE
PARK RIDGE IL
60068-2561
US

V. Phone/Fax

Practice location:
  • Phone: 708-202-8387
  • Fax:
Mailing address:
  • Phone: 847-696-2468
  • 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: