MEDICARE: MICHELLE LYNNEA ANTOLAK PHARMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	051.294801	IL

General Provider Information

NPI Number	:	1023304458
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE LYNNEA ANTOLAK PHARMD

Provider Business Mailing Address
First Line	:	2939 W ADDISON ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-4635
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2939 W ADDISON ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-4635
Country	:	US
Telephone Number	:	773-604-7680
Fax Number	:	773-604-7680

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/23/2011
Last Update Date	:	06/23/2011

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