Provider Demographics
NPI:1265712848
Name:KIELBASA, ADAM W (PHARMD)
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:W
Last Name:KIELBASA
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 1:6800 OGDEN AVE
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-3643
Mailing Address - Country:US
Mailing Address - Phone:708-749-9061
Mailing Address - Fax:
Practice Address - Street 1:6800 OGDEN AVE
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-3643
Practice Address - Country:US
Practice Address - Phone:708-749-9061
Practice Address - Fax:708-749-2478
Is Sole Proprietor?:No
Enumeration Date:2011-08-26
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051289972183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist