Healthcare Provider Details

I. General information

NPI: 1700452091
Provider Name (Legal Business Name): KRYSTIAN J WOJDYLA PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2021
Last Update Date: 05/27/2021
Certification Date: 05/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 E WALNUT ST
WATSEKA IL
60970-1359
US

IV. Provider business mailing address

14930 W WHITNEY ST
MANHATTAN IL
60442-5047
US

V. Phone/Fax

Practice location:
  • Phone: 815-432-4172
  • Fax:
Mailing address:
  • Phone: 773-669-5797
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051.303877
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: