Provider Demographics
NPI:1073883245
Name:WEDRYK, TERESA
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:WEDRYK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13137 S MUSKEGON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60633-1718
Mailing Address - Country:US
Mailing Address - Phone:773-646-4866
Mailing Address - Fax:
Practice Address - Street 1:3564 RIDGE RD
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:IL
Practice Address - Zip Code:60438-3315
Practice Address - Country:US
Practice Address - Phone:708-895-7937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-05
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.287331183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist