Healthcare Provider Details

I. General information

NPI: 1013481555
Provider Name (Legal Business Name): ALEC WESOLOWSKI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2019
Last Update Date: 07/03/2022
Certification Date: 07/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1775 DEMPSTER ST
PARK RIDGE IL
60068-1143
US

IV. Provider business mailing address

421 E THACH AVE
AUBURN AL
36830-5539
US

V. Phone/Fax

Practice location:
  • Phone: 847-273-7519
  • Fax:
Mailing address:
  • Phone: 954-815-2773
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberS12352
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051304054
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: