Provider Demographics
NPI:1730273376
Name:GERSTEN, MICHAEL (RPH)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:GERSTEN
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 1:1407 W. MORSE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626
Mailing Address - Country:US
Mailing Address - Phone:773-743-8400
Mailing Address - Fax:773-743-8492
Practice Address - Street 1:1407 W. MORSE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60626
Practice Address - Country:US
Practice Address - Phone:773-743-8400
Practice Address - Fax:773-743-8492
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0054000352183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL361505280001Medicaid
IL361505280001Medicaid