Provider Demographics
NPI:1821428194
Name:STATKEVICIUS, ASTA (PHARMD, RPH)
Entity Type:Individual
Prefix:
First Name:ASTA
Middle Name:
Last Name:STATKEVICIUS
Suffix:
Gender:F
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17648 CRESTVIEW CT
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60467-7531
Mailing Address - Country:US
Mailing Address - Phone:708-248-0838
Mailing Address - Fax:
Practice Address - Street 1:599 ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-5797
Practice Address - Country:US
Practice Address - Phone:630-790-2294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-22
Last Update Date:2013-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.296355183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist