=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154807808
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL JOHN BORAK
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/16/2018
-----------------------------------------------------
Last Update Date | 07/16/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 975 S ANNIE GLIDDEN ROAD SCHNUCKS MARKET INC
-----------------------------------------------------
City | DEKALB
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-748-6202
-----------------------------------------------------
Fax | 815-748-6202
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 975 S ANNIE GLIDDEN RD
-----------------------------------------------------
City | DEKALB
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60115-5838
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-748-6202
-----------------------------------------------------
Fax | 815-748-6203
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1835P2201X
-----------------------------------------------------
Taxonomy Name | Ambulatory Care Pharmacist
-----------------------------------------------------
License Number | 051034277
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------