Provider Demographics
NPI:1538516752
Name:MIETUS, PATRYCJA B (PHARMD)
Entity Type:Individual
Prefix:
First Name:PATRYCJA
Middle Name:B
Last Name:MIETUS
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6107 S ARCHER AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60638-2743
Mailing Address - Country:US
Mailing Address - Phone:773-735-0396
Mailing Address - Fax:
Practice Address - Street 1:6107 S ARCHER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60638-2743
Practice Address - Country:US
Practice Address - Phone:773-735-0396
Practice Address - Fax:773-735-1256
Is Sole Proprietor?:No
Enumeration Date:2016-05-17
Last Update Date:2016-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.296853183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist