Provider Demographics
NPI:1669934089
Name:LIS, KINGA EWA (PHARMD)
Entity type:Individual
Prefix:
First Name:KINGA
Middle Name:EWA
Last Name:LIS
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 1:5000 S 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:HINES
Mailing Address - State:IL
Mailing Address - Zip Code:60141-3030
Mailing Address - Country:US
Mailing Address - Phone:708-202-1977
Mailing Address - Fax:
Practice Address - Street 1:5000 S 5TH AVE
Practice Address - Street 2:
Practice Address - City:HINES
Practice Address - State:IL
Practice Address - Zip Code:60141-3030
Practice Address - Country:US
Practice Address - Phone:708-202-1977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-03
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051300536183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL051300536OtherREGISTERED PHARMACIST LICENSE