=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700965670
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARISCELLE M. SALES PHARM.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | VA PBM/SHG (119D), 1ST AVE - 1 BLOCK NORTH OF CERMAK RD BUILDING 37, ROOM 139
-----------------------------------------------------
City | HINES
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60141
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-786-7862
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8849 S WASHTENAW AVE
-----------------------------------------------------
City | EVERGREEN PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60805-1134
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-423-8835
-----------------------------------------------------
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 | 51287877
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------