Provider Demographics
NPI:1477658078
Name:EZAKI, GLEN LEWIS (RPH)
Entity Type:Individual
Prefix:MR
First Name:GLEN
Middle Name:LEWIS
Last Name:EZAKI
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:155 N HARBOR DR
Mailing Address - Street 2:4402
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-7364
Mailing Address - Country:US
Mailing Address - Phone:312-569-7109
Mailing Address - Fax:312-569-8028
Practice Address - Street 1:820 S DAMEN AVE
Practice Address - Street 2:(119)
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3728
Practice Address - Country:US
Practice Address - Phone:312-565-7109
Practice Address - Fax:312-569-8028
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist