Healthcare Provider Details

I. General information

NPI: 1235408923
Provider Name (Legal Business Name): PIOTR WYCZESANY PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/24/2011
Last Update Date: 12/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 N LOMBARD ST
MAHOMET IL
61853-9097
US

IV. Provider business mailing address

6807 N MILWAUKEE AVE APT 607
NILES IL
60714-4565
US

V. Phone/Fax

Practice location:
  • Phone: 847-962-2865
  • Fax:
Mailing address:
  • Phone: 847-962-2865
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051.295060
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: