Provider Demographics
NPI:1013290733
Name:PIETSCH, LYSLE R
Entity Type:Individual
Prefix:MR
First Name:LYSLE
Middle Name:R
Last Name:PIETSCH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2040 ARMY TRAIL RD
Mailing Address - Street 2:
Mailing Address - City:HANOVER PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60133-8975
Mailing Address - Country:US
Mailing Address - Phone:630-830-6451
Mailing Address - Fax:
Practice Address - Street 1:2040 ARMY TRAIL RD
Practice Address - Street 2:
Practice Address - City:HANOVER PARK
Practice Address - State:IL
Practice Address - Zip Code:60133-8975
Practice Address - Country:US
Practice Address - Phone:630-830-6451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-20
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051028556183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist