Healthcare Provider Details

I. General information

NPI: 1265888705
Provider Name (Legal Business Name): TERRI KSIAZEK RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2016
Last Update Date: 05/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4650 W 103RD ST
OAK LAWN IL
60453-4719
US

IV. Provider business mailing address

4650 W 103RD ST
OAK LAWN IL
60453-4719
US

V. Phone/Fax

Practice location:
  • Phone: 708-422-2334
  • Fax: 708-422-0703
Mailing address:
  • Phone: 708-422-2334
  • Fax: 708-422-0703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051.289242
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: