Healthcare Provider Details

I. General information

NPI: 1760086151
Provider Name (Legal Business Name): AGNIESZKA WALCZAK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/25/2020
Last Update Date: 11/25/2020
Certification Date: 11/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4050 N HARLEM AVE
NORRIDGE IL
60706-1328
US

IV. Provider business mailing address

4050 N HARLEM AVE
NORRIDGE IL
60706-1328
US

V. Phone/Fax

Practice location:
  • Phone: 708-583-6990
  • Fax:
Mailing address:
  • Phone: 708-583-6990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051.295571
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: