Healthcare Provider Details

I. General information

NPI: 1316004385
Provider Name (Legal Business Name): MICHAEL MA PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 10/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 SKOKIE BLVD SUITE 600
NORTHBROOK IL
60062-2857
US

IV. Provider business mailing address

321 25TH AVE
BELLWOOD IL
60104-1517
US

V. Phone/Fax

Practice location:
  • Phone: 708-362-9860
  • Fax:
Mailing address:
  • Phone: 708-362-9860
  • Fax: 847-291-8492

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051288705
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1835N0905X
TaxonomyNuclear Pharmacist
License Number55576
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: