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General NPI Number Information
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NPI Number | 1124305677
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Entity Type | Individual
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Provider Name | KENNETH BRUCE HAYDEK RPH
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Gender | Male
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Dates
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Enumeration Date | 11/11/2011
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Last Update Date | 11/11/2011
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Provider Practice Location Address
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Address Line | 4000 W 59TH ST
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City | CHICAGO
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State | IL
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Zip | 60629-4512
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Country | US
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Telephone | 773-581-2345
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Fax |
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Provider Business Mailing Address
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Address Line | 8442 ORENIA CT
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City | ORLAND PARK
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State | IL
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Zip | 60462-1629
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Country | US
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Telephone | 708-349-1659
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 051-032598
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License Number State | IL
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