Healthcare Provider Details

I. General information

NPI: 1790951689
Provider Name (Legal Business Name): MRS. KIMBERLY DENISE CICHY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2008
Last Update Date: 08/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2363 63RD ST
WOODRIDGE IL
60517-1369
US

IV. Provider business mailing address

2363 63RD ST
WOODRIDGE IL
60517-1369
US

V. Phone/Fax

Practice location:
  • Phone: 708-493-9084
  • Fax: 708-493-9089
Mailing address:
  • Phone: 630-493-9084
  • Fax: 630-493-9089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051-039844
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: