Provider Demographics
NPI:1932480522
Name:FABISZAK, CARL ANTHONY (RPH)
Entity Type:Individual
Prefix:MR
First Name:CARL
Middle Name:ANTHONY
Last Name:FABISZAK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9625 S TRIPP AVE
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-3236
Mailing Address - Country:US
Mailing Address - Phone:708-423-8288
Mailing Address - Fax:
Practice Address - Street 1:8700 S KEDZIE AVE
Practice Address - Street 2:
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-1024
Practice Address - Country:US
Practice Address - Phone:708-499-8051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-08
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051029554183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist