Provider Demographics
NPI:1538516653
Name:SOBOTA, WAYNE (RPH)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:
Last Name:SOBOTA
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 1:1380 LONDON RD
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-9738
Mailing Address - Country:US
Mailing Address - Phone:815-485-6007
Mailing Address - Fax:708-532-7391
Practice Address - Street 1:17113 HARLEM AVE
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-3369
Practice Address - Country:US
Practice Address - Phone:708-532-7477
Practice Address - Fax:708-532-7391
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-18
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILIL051028899183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist