Healthcare Provider Details

I. General information

NPI: 1467057182
Provider Name (Legal Business Name): MELISSA KATHLEEN MCLEAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2020
Last Update Date: 12/01/2020
Certification Date: 12/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1165 N CLARK ST
CHICAGO IL
60610-2702
US

IV. Provider business mailing address

1165 N CLARK ST
CHICAGO IL
60610-2702
US

V. Phone/Fax

Practice location:
  • Phone: 312-280-8140
  • Fax: 312-280-8495
Mailing address:
  • Phone: 312-280-8140
  • Fax: 312-280-8495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051.292004
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: