Provider Demographics
NPI:1578832283
Name:WISNIEWSKI, SAMANTHA (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:
Last Name:WISNIEWSKI
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 1:12300 S IL ROUTE 47
Mailing Address - Street 2:
Mailing Address - City:HUNTLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60142-9634
Mailing Address - Country:US
Mailing Address - Phone:847-669-7563
Mailing Address - Fax:847-669-7609
Practice Address - Street 1:12300 S IL ROUTE 47
Practice Address - Street 2:
Practice Address - City:HUNTLEY
Practice Address - State:IL
Practice Address - Zip Code:60142-9634
Practice Address - Country:US
Practice Address - Phone:847-669-7563
Practice Address - Fax:847-669-7609
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-26
Last Update Date:2011-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.290487183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist