Provider Demographics
NPI:1710573837
Name:CHAVEZ, ANITA
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:
Last Name:CHAVEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11021 LINN CT
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE HIGHLANDS
Mailing Address - State:IL
Mailing Address - Zip Code:60525-7313
Mailing Address - Country:US
Mailing Address - Phone:708-830-3025
Mailing Address - Fax:
Practice Address - Street 1:7910 S CICERO AVE
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:IL
Practice Address - Zip Code:60459-1507
Practice Address - Country:US
Practice Address - Phone:708-423-2700
Practice Address - Fax:708-423-2582
Is Sole Proprietor?:No
Enumeration Date:2020-12-13
Last Update Date:2020-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.303676183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist