Provider Demographics
NPI:1598034696
Name:CIESLA, MITCHELL (RPH)
Entity Type:Individual
Prefix:MR
First Name:MITCHELL
Middle Name:
Last Name:CIESLA
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 1:10532 S TRIPP AVE
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-4948
Mailing Address - Country:US
Mailing Address - Phone:708-425-8764
Mailing Address - Fax:708-425-9543
Practice Address - Street 1:10532 S TRIPP AVE
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-4948
Practice Address - Country:US
Practice Address - Phone:708-425-8764
Practice Address - Fax:708-425-9543
Is Sole Proprietor?:No
Enumeration Date:2011-12-19
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051029144183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist