Provider Demographics
NPI:1124305677
Name:HAYDEK, KENNETH BRUCE (RPH)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:BRUCE
Last Name:HAYDEK
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 1:8442 ORENIA CT
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-1629
Mailing Address - Country:US
Mailing Address - Phone:708-349-1659
Mailing Address - Fax:
Practice Address - Street 1:4000 W 59TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-4512
Practice Address - Country:US
Practice Address - Phone:773-581-2345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-11
Last Update Date:2011-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-032598183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist