=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245836097
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY C YERKES RPH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/08/2020
-----------------------------------------------------
Last Update Date | 12/08/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 675 W NORTH AVE
-----------------------------------------------------
City | MELROSE PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60160-1630
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-538-4941
-----------------------------------------------------
Fax | 708-538-4673
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 36 FOREST AVE
-----------------------------------------------------
City | RIVER FOREST
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60305-2002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-860-8509
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 051034318
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------