Healthcare Provider Details

I. General information

NPI: 1295089761
Provider Name (Legal Business Name): MARISSA KUOK PHARM D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARISSA NILL PHARM D

II. Dates (important events)

Enumeration Date: 11/05/2012
Last Update Date: 12/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3860 W OGDEN AVE PHARMACY
CHICAGO IL
60623-2460
US

IV. Provider business mailing address

3860 W OGDEN AVE PHARMACY
CHICAGO IL
60623-2460
US

V. Phone/Fax

Practice location:
  • Phone: 872-588-3256
  • Fax:
Mailing address:
  • Phone: 872-588-3256
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051292142
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302034523
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: