Provider Demographics
NPI:1801836739
Name:KOVAK, GREGORY S (PHARMACIST)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:S
Last Name:KOVAK
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9511 W HIGGINS RD
Mailing Address - Street 2:
Mailing Address - City:ROSEMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60018-4905
Mailing Address - Country:US
Mailing Address - Phone:847-292-8989
Mailing Address - Fax:847-292-8990
Practice Address - Street 1:9511 W HIGGINS RD
Practice Address - Street 2:
Practice Address - City:ROSEMONT
Practice Address - State:IL
Practice Address - Zip Code:60018-4905
Practice Address - Country:US
Practice Address - Phone:847-292-8989
Practice Address - Fax:847-292-8990
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL200954033001Medicaid
IL209601OtherCLIA
IL200954033001Medicaid