MEDICARE: MR. ROBERT C WILSAK 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	051-031192	IL

General Provider Information

NPI Number	:	1235414749
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ROBERT C WILSAK RPH

Provider Business Mailing Address
First Line	:	12659 S RIDGELAND AVE
Second Line	:
City	:	PALOS HEIGHTS
State	:	IL
Zip	:	60463-1871
Country	:	US
Telephone Number	:	708-385-0218
Fax Number	:

Provider Business Practice Location Address
First Line	:	12659 S RIDGELAND AVE
Second Line	:
City	:	PALOS HEIGHTS
State	:	IL
Zip	:	60463-1871
Country	:	US
Telephone Number	:	708-385-0218
Fax Number	:

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

Provider Enumeration Date	:	10/15/2011
Last Update Date	:	10/15/2011

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