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General NPI Number Information
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NPI Number | 1992316079
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Entity Type | Individual
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Provider Name | GRANT J GORNICK
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Gender | Male
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Dates
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Enumeration Date | 08/12/2020
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Last Update Date | 08/12/2020
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Provider Practice Location Address
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Address Line | 4385 S ARCHER AVE
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City | CHICAGO
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State | IL
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Zip | 60632-2810
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Country | US
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Telephone | 773-247-6804
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Fax |
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Provider Business Mailing Address
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Address Line | 7825 W 100TH PL
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City | PALOS HILLS
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State | IL
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Zip | 60465-1512
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Country | US
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Telephone | 708-612-4407
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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 | 051302305
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License Number State | IL
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