Provider Demographics
NPI:1982716601
Name:MIRECKI, EDMUND VINCENT (RPH)
Entity Type:Individual
Prefix:MR
First Name:EDMUND
Middle Name:VINCENT
Last Name:MIRECKI
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 N PARK RD
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-1854
Mailing Address - Country:US
Mailing Address - Phone:708-354-4335
Mailing Address - Fax:773-579-0427
Practice Address - Street 1:4710 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60609-4060
Practice Address - Country:US
Practice Address - Phone:773-579-0366
Practice Address - Fax:773-579-0427
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist