Healthcare Provider Details

I. General information

NPI: 1437755295
Provider Name (Legal Business Name): MARSHALL LEE PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2020
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3680 WASHINGTON AVE APT C
GREAT LAKES IL
60088-1737
US

IV. Provider business mailing address

3680 WASHINGTON AVE APT C
GREAT LAKES IL
60088-1737
US

V. Phone/Fax

Practice location:
  • Phone: 612-759-9260
  • Fax:
Mailing address:
  • Phone: 612-759-9260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number051.302482
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: