Provider Demographics
NPI:1659537934
Name:WIRTH, PRIYATMA (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:PRIYATMA
Middle Name:
Last Name:WIRTH
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 1:214 NORTHWOOD RD
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60546-1834
Mailing Address - Country:US
Mailing Address - Phone:815-275-5519
Mailing Address - Fax:
Practice Address - Street 1:5000 S 5TH AVE
Practice Address - Street 2:BUILDING 217, ROOM 2B7
Practice Address - City:HINES
Practice Address - State:IL
Practice Address - Zip Code:60141-3030
Practice Address - Country:US
Practice Address - Phone:708-202-2134
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-05
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0512920651835P0018X, 1835G0303X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835G0303XPharmacy Service ProvidersPharmacistGeriatric
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist