Provider Demographics
NPI:1528415411
Name:CISMESIA, CHARLENE
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:
Last Name:CISMESIA
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 1:760 W ARMY TRAIL RD
Mailing Address - Street 2:
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60188-9297
Mailing Address - Country:US
Mailing Address - Phone:630-289-3777
Mailing Address - Fax:630-289-4359
Practice Address - Street 1:760 W ARMY TRAIL RD
Practice Address - Street 2:
Practice Address - City:CAROL STREAM
Practice Address - State:IL
Practice Address - Zip Code:60188-9297
Practice Address - Country:US
Practice Address - Phone:630-289-3777
Practice Address - Fax:630-289-4359
Is Sole Proprietor?:No
Enumeration Date:2016-05-20
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051032348183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist