Healthcare Provider Details

I. General information

NPI: 1669715967
Provider Name (Legal Business Name): MARY PUBENTZ R.PH.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2013
Last Update Date: 04/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 GOLF RD SUITE 2-1100
ROLLING MEADOWS IL
60008-4227
US

IV. Provider business mailing address

1701 GOLF RD SUITE 2-1100
ROLLING MEADOWS IL
60008-4227
US

V. Phone/Fax

Practice location:
  • Phone: 847-635-4412
  • Fax: 847-635-5915
Mailing address:
  • Phone: 847-635-4412
  • Fax: 847-635-5915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051-039039
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: