Provider Demographics
NPI:1144201054
Name:MROZ, GARY S
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:S
Last Name:MROZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2531 N EAST BROOK RD
Mailing Address - Street 2:
Mailing Address - City:ELMWOOD PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60707-2446
Mailing Address - Country:US
Mailing Address - Phone:708-453-2152
Mailing Address - Fax:
Practice Address - Street 1:4820 N CUMBERLAND AVE
Practice Address - Street 2:
Practice Address - City:NORRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60706-2914
Practice Address - Country:US
Practice Address - Phone:708-583-2133
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist