Provider Demographics
NPI:1861434581
Name:VIVIRITO, WAYNE M (RPH)
Entity type:Individual
Prefix:MR
First Name:WAYNE
Middle Name:M
Last Name:VIVIRITO
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 1:118 WINDDANCE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE VILLA
Mailing Address - State:IL
Mailing Address - Zip Code:60046-6670
Mailing Address - Country:US
Mailing Address - Phone:847-356-6156
Mailing Address - Fax:
Practice Address - Street 1:1451 PETERSON RD
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-1001
Practice Address - Country:US
Practice Address - Phone:847-573-8067
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist