Provider Demographics
NPI:1396249520
Name:MACASO, JENNY ROSILLO
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:ROSILLO
Last Name:MACASO
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 1:11600 S KEDZIE AVE STE E
Mailing Address - Street 2:
Mailing Address - City:MERRIONETTE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60803-6308
Mailing Address - Country:US
Mailing Address - Phone:708-389-5300
Mailing Address - Fax:
Practice Address - Street 1:11600 S KEDZIE AVE
Practice Address - Street 2:
Practice Address - City:MERRIONETTE PARK
Practice Address - State:IL
Practice Address - Zip Code:60803-6307
Practice Address - Country:US
Practice Address - Phone:708-389-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-21
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051300099183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL051300099OtherREGISTERED PHARMACIST