Healthcare Provider Details

I. General information

NPI: 1205120151
Provider Name (Legal Business Name): MARISOL CAW PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2011
Last Update Date: 06/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2656 N ELSTON AVE
CHICAGO IL
60647-2019
US

IV. Provider business mailing address

2656 N ELSTON AVE
CHICAGO IL
60647-2019
US

V. Phone/Fax

Practice location:
  • Phone: 773-252-2210
  • Fax: 773-252-2210
Mailing address:
  • Phone: 773-252-2210
  • Fax: 773-252-2210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051289078
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: