=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801957782
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK CONLIN RPH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2006
-----------------------------------------------------
Last Update Date | 01/01/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1615 N STATE ROUTE 50
-----------------------------------------------------
City | BOURBONNAIS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60914-9324
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-933-1777
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12035 LANCASTER CT
-----------------------------------------------------
City | ORLAND PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60467-1143
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-301-3305
-----------------------------------------------------
Fax | 708-301-6529
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 051033743
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 26023410A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------