Provider Demographics
NPI:1154607133
Name:VACLAVEK, MARTIN PAUL (RPH)
Entity type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:PAUL
Last Name:VACLAVEK
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 1:6240 BELMONT RD
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60516-1638
Mailing Address - Country:US
Mailing Address - Phone:630-960-4160
Mailing Address - Fax:630-960-4651
Practice Address - Street 1:6240 BELMONT RD
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60516-1638
Practice Address - Country:US
Practice Address - Phone:630-960-4160
Practice Address - Fax:630-960-4651
Is Sole Proprietor?:No
Enumeration Date:2011-10-22
Last Update Date:2011-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051034380183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist