Provider Demographics
NPI:1235414749
Name:WILSAK, ROBERT C (RPH)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:C
Last Name:WILSAK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12659 S RIDGELAND AVE
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1871
Mailing Address - Country:US
Mailing Address - Phone:708-385-0218
Mailing Address - Fax:
Practice Address - Street 1:12659 S RIDGELAND AVE
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1871
Practice Address - Country:US
Practice Address - Phone:708-385-0218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-15
Last Update Date:2011-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-031192183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist