Provider Demographics
NPI:1386094191
Name:MAZIARZ, GINA
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:MAZIARZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 N US HIGHWAY 12
Mailing Address - Street 2:
Mailing Address - City:SPRING GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60081-9691
Mailing Address - Country:US
Mailing Address - Phone:815-675-6984
Mailing Address - Fax:
Practice Address - Street 1:2401 N US HIGHWAY 12
Practice Address - Street 2:
Practice Address - City:SPRING GROVE
Practice Address - State:IL
Practice Address - Zip Code:60081-9691
Practice Address - Country:US
Practice Address - Phone:815-675-6984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-13
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.288361183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist