Healthcare Provider Details

I. General information

NPI: 1972929883
Provider Name (Legal Business Name): MARA MICHAUD PHARM.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. MARGERY HAYNES

II. Dates (important events)

Enumeration Date: 03/16/2014
Last Update Date: 03/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2611 W CHICAGO AVE
CHICAGO IL
60622-4519
US

IV. Provider business mailing address

1606 COYOTE RIDGE DR
PLAINFIELD IL
60586-2509
US

V. Phone/Fax

Practice location:
  • Phone: 773-395-9900
  • Fax:
Mailing address:
  • Phone: 312-351-0733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number51296161
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number26025000A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number17326-40
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH60336590
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: