Provider Demographics
NPI:1770246100
Name:ANTOLAK, ALEXANDER A (PHARMD)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:A
Last Name:ANTOLAK
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 N NORTHWEST HWY
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-3254
Mailing Address - Country:US
Mailing Address - Phone:773-366-1099
Mailing Address - Fax:
Practice Address - Street 1:4320 SE KING RD
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-5281
Practice Address - Country:US
Practice Address - Phone:503-659-1840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-21
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051304393183500000X
ORRPH-0019372183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist