MEDICARE: NIDA M PETRONIS 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		IL

General Provider Information

NPI Number	:	1578506036
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NIDA M PETRONIS RPH

Provider Business Mailing Address
First Line	:	6613 WESTERN AVE
Second Line	:
City	:	WILLOW BROOK
State	:	IL
Zip	:	60527-1878
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2205 W 22ND ST
Second Line	:
City	:	OAK BROOK
State	:	IL
Zip	:	60523-1203
Country	:	US
Telephone Number	:	630-928-0386
Fax Number	:	630-928-0398

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

Provider Enumeration Date	:	06/13/2006
Last Update Date	:	07/08/2007

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