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General NPI Number Information
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NPI Number | 1497032395
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Entity Type | Individual
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Provider Name | VARISA MIMI SERIRODOM PHARM. D.
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Gender | Female
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Dates
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Enumeration Date | 11/07/2011
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Last Update Date | 11/07/2011
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Provider Practice Location Address
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Address Line | 8628 S COTTAGE GROVE AVE
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City | CHICAGO
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State | IL
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Zip | 60619-6108
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Country | US
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Telephone | 773-651-8500
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Fax | 773-874-0173
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Provider Business Mailing Address
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Address Line | 8775 S 80TH CT
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City | HICKORY HILLS
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State | IL
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Zip | 60457-1431
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Country | US
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Telephone |
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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 | 051291605
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License Number State | IL
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