Healthcare Provider Details

I. General information

NPI: 1700302270
Provider Name (Legal Business Name): MARK HOFELICH PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 CARLYLE AVENUE
BELLEVILLE IL
62221
US

IV. Provider business mailing address

515 CARLYLE AVE
BELLEVILLE IL
62221-6223
US

V. Phone/Fax

Practice location:
  • Phone: 618-222-1827
  • Fax:
Mailing address:
  • Phone: 618-222-1827
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number051300539
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: