Healthcare Provider Details

I. General information

NPI: 1750937314
Provider Name (Legal Business Name): MARIANNE TRGOVICH RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2019
Last Update Date: 08/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 JOLIET ST
DYER IN
46311-1709
US

IV. Provider business mailing address

225 JOLIET ST
DYER IN
46311-1709
US

V. Phone/Fax

Practice location:
  • Phone: 219-322-3014
  • Fax: 219-322-3307
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number26026113A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: