Provider Demographics
NPI:1790951689
Name:CICHY, KIMBERLY DENISE
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:DENISE
Last Name:CICHY
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 1:2363 63RD ST
Mailing Address - Street 2:
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-1369
Mailing Address - Country:US
Mailing Address - Phone:630-493-9084
Mailing Address - Fax:630-493-9089
Practice Address - Street 1:2363 63RD ST
Practice Address - Street 2:
Practice Address - City:WOODRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60517-1369
Practice Address - Country:US
Practice Address - Phone:708-493-9084
Practice Address - Fax:708-493-9089
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-01
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-039844183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist