Healthcare Provider Details

I. General information

NPI: 1376469932
Provider Name (Legal Business Name): MARY ANGELINE VALDES LACSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2026
Last Update Date: 06/27/2026
Certification Date: 06/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1145 N ALPINE RD
ROCKFORD IL
61107-3613
US

IV. Provider business mailing address

990 LEEWARD LN
PINGREE GROVE IL
60140-2006
US

V. Phone/Fax

Practice location:
  • Phone: 815-398-2443
  • Fax:
Mailing address:
  • Phone: 773-951-1547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051.308449
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: