Provider Demographics
NPI:1801491428
Name:DAWIDOWICZ, DIANE
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:DAWIDOWICZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11200 LINCOLN HWY
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-8208
Mailing Address - Country:US
Mailing Address - Phone:815-464-2171
Mailing Address - Fax:
Practice Address - Street 1:11200 LINCOLN HWY
Practice Address - Street 2:
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-8208
Practice Address - Country:US
Practice Address - Phone:815-464-2171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051290050183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist