Healthcare Provider Details

I. General information

NPI: 1306458252
Provider Name (Legal Business Name): DAMIAN WOLAK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2020
Last Update Date: 08/21/2020
Certification Date: 08/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4820 N CUMBERLAND AVE
NORRIDGE IL
60706-2914
US

IV. Provider business mailing address

4820 N CUMBERLAND AVE
NORRIDGE IL
60706-2914
US

V. Phone/Fax

Practice location:
  • Phone: 708-583-2133
  • Fax: 708-583-2371
Mailing address:
  • Phone: 708-583-2133
  • Fax: 708-583-2371

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051298741
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: