Provider Demographics
NPI:1417239120
Name:MAVROVIC, GREGORY M (PHARMD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:M
Last Name:MAVROVIC
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15234 WOODMAR DR
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-4144
Mailing Address - Country:US
Mailing Address - Phone:708-460-4589
Mailing Address - Fax:
Practice Address - Street 1:11833 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-4733
Practice Address - Country:US
Practice Address - Phone:773-233-2245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-20
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.293643183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist