Provider Demographics
NPI:1770865610
Name:KOSTICH, GORDANA (RPH)
Entity Type:Individual
Prefix:
First Name:GORDANA
Middle Name:
Last Name:KOSTICH
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 NELSON LN
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-2893
Mailing Address - Country:US
Mailing Address - Phone:630-829-4081
Mailing Address - Fax:
Practice Address - Street 1:4101 1ST AVE
Practice Address - Street 2:
Practice Address - City:LYONS
Practice Address - State:IL
Practice Address - Zip Code:60534-1028
Practice Address - Country:US
Practice Address - Phone:708-447-6851
Practice Address - Fax:708-447-0568
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-16
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051037805183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist