MEDICARE: MR. MARTIN PAUL VACLAVEK RPH

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	051034380	IL

General Provider Information

NPI Number	:	1154607133
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARTIN PAUL VACLAVEK RPH

Provider Business Mailing Address
First Line	:	6240 BELMONT RD
Second Line	:
City	:	DOWNERS GROVE
State	:	IL
Zip	:	60516-1638
Country	:	US
Telephone Number	:	630-960-4160
Fax Number	:	630-960-4651

Provider Business Practice Location Address
First Line	:	6240 BELMONT RD
Second Line	:
City	:	DOWNERS GROVE
State	:	IL
Zip	:	60516-1638
Country	:	US
Telephone Number	:	630-960-4160
Fax Number	:	630-960-4651

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

Provider Enumeration Date	:	10/22/2011
Last Update Date	:	10/22/2011

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