Provider Demographics
NPI:1053698787
Name:LANGE, WENDY
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:
Last Name:LANGE
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 1:5435 S KEDZIE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60632-2642
Mailing Address - Country:US
Mailing Address - Phone:773-436-7396
Mailing Address - Fax:773-436-7687
Practice Address - Street 1:5435 S KEDZIE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60632-2642
Practice Address - Country:US
Practice Address - Phone:773-436-7396
Practice Address - Fax:773-436-7687
Is Sole Proprietor?:No
Enumeration Date:2011-11-09
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051040950183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist