Provider Demographics
NPI:1780097907
Name:JANICZAK, SCOTT
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:JANICZAK
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 1:13840 S TEAKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:HOMER GLEN
Mailing Address - State:IL
Mailing Address - Zip Code:60491-8694
Mailing Address - Country:US
Mailing Address - Phone:708-308-6474
Mailing Address - Fax:
Practice Address - Street 1:13840 S TEAKWOOD DR
Practice Address - Street 2:
Practice Address - City:HOMER GLEN
Practice Address - State:IL
Practice Address - Zip Code:60491-8694
Practice Address - Country:US
Practice Address - Phone:708-308-6474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-05
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.294944183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist