Provider Demographics
NPI:1194507285
Name:WAGREZ, NINA
Entity type:Individual
Prefix:
First Name:NINA
Middle Name:
Last Name:WAGREZ
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 1:21W454 THORNDALE AVE
Mailing Address - Street 2:
Mailing Address - City:MEDINAH
Mailing Address - State:IL
Mailing Address - Zip Code:60157-9631
Mailing Address - Country:US
Mailing Address - Phone:224-231-8135
Mailing Address - Fax:
Practice Address - Street 1:153 E SCHILLER ST
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-2869
Practice Address - Country:US
Practice Address - Phone:630-530-8790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-16
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183700000XPharmacy Service ProvidersPharmacy TechnicianGroup - Single Specialty