Healthcare Provider Details

I. General information

NPI: 1073883245
Provider Name (Legal Business Name): TERESA WEDRYK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2012
Last Update Date: 01/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3564 RIDGE RD
LANSING IL
60438-3315
US

IV. Provider business mailing address

13137 S MUSKEGON AVE
CHICAGO IL
60633-1718
US

V. Phone/Fax

Practice location:
  • Phone: 708-895-7937
  • Fax:
Mailing address:
  • Phone: 773-646-4866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051.287331
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: