Provider Demographics
NPI:1043860877
Name:VAZQUEZ CERVANTES, VICTOR MANUEL (PHARMD)
Entity type:Individual
Prefix:
First Name:VICTOR
Middle Name:MANUEL
Last Name:VAZQUEZ CERVANTES
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:669 N BRIAR HILL LN APT 5
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:IL
Mailing Address - Zip Code:60101-2243
Mailing Address - Country:US
Mailing Address - Phone:312-307-0339
Mailing Address - Fax:
Practice Address - Street 1:2080 NO, IL-50
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914
Practice Address - Country:US
Practice Address - Phone:815-937-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-13
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051302276183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist