Healthcare Provider Details

I. General information

NPI: 1023418019
Provider Name (Legal Business Name): MALLORY FOWLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2014
Last Update Date: 08/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 S 5TH AVE
HINES IL
60141-3030
US

IV. Provider business mailing address

5207 S BLACKSTONE AVE UNIT 2
CHICAGO IL
60615-4126
US

V. Phone/Fax

Practice location:
  • Phone: 708-202-2988
  • Fax:
Mailing address:
  • Phone: 219-718-0145
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051.297808
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: