Provider Demographics
NPI:1639295140
Name:GAJEWICZ, THOMAS CONRAD (RPH)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:CONRAD
Last Name:GAJEWICZ
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 1:5922 N KEATING AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-5703
Mailing Address - Country:US
Mailing Address - Phone:773-545-5863
Mailing Address - Fax:
Practice Address - Street 1:5922 N KEATING AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-5703
Practice Address - Country:US
Practice Address - Phone:773-545-5863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist