Healthcare Provider Details

I. General information

NPI: 1144201054
Provider Name (Legal Business Name): MR. GARY S. MROZ
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4820 N CUMBERLAND AVE
NORRIDGE IL
60706-2914
US

IV. Provider business mailing address

2531 N EAST BROOK RD
ELMWOOD PARK IL
60707-2446
US

V. Phone/Fax

Practice location:
  • Phone: 708-583-2133
  • Fax:
Mailing address:
  • Phone: 708-453-2152
  • 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: