Provider Demographics
NPI:1043660707
Name:MIERZWA, KEITH
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:MIERZWA
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 1:966 ROUTE 59
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:IL
Mailing Address - Zip Code:60002
Mailing Address - Country:US
Mailing Address - Phone:847-395-7101
Mailing Address - Fax:847-395-3112
Practice Address - Street 1:966 ROUTE 59
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:IL
Practice Address - Zip Code:60002
Practice Address - Country:US
Practice Address - Phone:847-395-7101
Practice Address - Fax:847-395-3112
Is Sole Proprietor?:No
Enumeration Date:2016-06-14
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051033283183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist