Provider Demographics
NPI:1184055139
Name:GIMBAR, RENEE PETZEL (PHARMD)
Entity type:Individual
Prefix:DR
First Name:RENEE
Middle Name:PETZEL
Last Name:GIMBAR
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1349 W FILLMORE ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-4806
Mailing Address - Country:US
Mailing Address - Phone:708-772-0112
Mailing Address - Fax:
Practice Address - Street 1:833 S WOOD ST
Practice Address - Street 2:SUITE 164
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-7229
Practice Address - Country:US
Practice Address - Phone:312-413-9828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-02
Last Update Date:2013-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0512900091835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist