Healthcare Provider Details

I. General information

NPI: 1952306151
Provider Name (Legal Business Name): LISA C MONDIE R.PH.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2005
Last Update Date: 08/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7845 S COTTAGE GROVE AVE SUITE 100
CHICAGO IL
60619-3100
US

IV. Provider business mailing address

7774 S KARLOV AVE
CHICAGO IL
60652-1225
US

V. Phone/Fax

Practice location:
  • Phone: 773-873-4400
  • Fax: 773-873-5635
Mailing address:
  • Phone: 773-582-9789
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: