Provider Demographics
NPI:1902201437
Name:JURICHKO, THEODORA KAPOS (RPH)
Entity Type:Individual
Prefix:MRS
First Name:THEODORA
Middle Name:KAPOS
Last Name:JURICHKO
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 1:1018 WESLEY AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-1161
Mailing Address - Country:US
Mailing Address - Phone:847-316-2677
Mailing Address - Fax:
Practice Address - Street 1:1018 WESLEY AVE
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-1161
Practice Address - Country:US
Practice Address - Phone:847-316-2677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-27
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.038204183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL363330928Medicaid