Provider Demographics
NPI:1194150912
Name:THIEBAUD, MARIBEL (PHARM D)
Entity type:Individual
Prefix:MISS
First Name:MARIBEL
Middle Name:
Last Name:THIEBAUD
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 N LAKEVIEW AVE APT 810
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-2734
Mailing Address - Country:US
Mailing Address - Phone:989-980-0083
Mailing Address - Fax:
Practice Address - Street 1:1601 N WELLS ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-6001
Practice Address - Country:US
Practice Address - Phone:312-642-4008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-11
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.296911183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist