Healthcare Provider Details

I. General information

NPI: 1134401185
Provider Name (Legal Business Name): MRS. MARNE FAY SNYDER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2011
Last Update Date: 09/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5140 W DIVERSEY AVE
CHICAGO IL
60639-1612
US

IV. Provider business mailing address

5140 W DIVERSEY AVE
CHICAGO IL
60639-1612
US

V. Phone/Fax

Practice location:
  • Phone: 773-685-8759
  • Fax: 773-685-1878
Mailing address:
  • Phone: 773-685-8759
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051289253
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: