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General NPI Number Information
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NPI Number | 1114295599
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Entity Type | Individual
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Provider Name | POLLY BHAMRA MALLINGA DOCTOR OF PHARMACY
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Gender | Female
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Dates
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Enumeration Date | 12/13/2011
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Last Update Date | 12/13/2011
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Provider Practice Location Address
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Address Line | 3564 RIDGE RD
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City | LANSING
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State | IL
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Zip | 60438
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Country | US
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Telephone | 708-895-7937
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Fax |
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Provider Business Mailing Address
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Address Line | 2934 IMPERIAL CT
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City | FLOSSMOOR
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State | IL
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Zip | 60422-2210
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Country | US
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Telephone | 708-957-3505
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 051.287846
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License Number State | IL
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