MEDICARE: MS. SUSAN ANN BRENIC 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	:	1861510349
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SUSAN ANN BRENIC RPH

Provider Business Mailing Address
First Line	:	1409 GRANVILLE AVE
Second Line	:
City	:	PARK RIDGE
State	:	IL
Zip	:	60068-5013
Country	:	US
Telephone Number	:	847-518-8782
Fax Number	:	847-929-3126

Provider Business Practice Location Address
First Line	:	3350 N WESTERN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-6213
Country	:	US
Telephone Number	:	773-929-1086
Fax Number	:	773-929-3126

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

Provider Enumeration Date	:	03/26/2007
Last Update Date	:	07/08/2007

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