Provider Demographics
NPI:1427330943
Name:MATUS DE LA PARRA, MARIEL INGRID (RPH)
Entity type:Individual
Prefix:
First Name:MARIEL
Middle Name:INGRID
Last Name:MATUS DE LA PARRA
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10824 N FIELDGROVE DR
Mailing Address - Street 2:
Mailing Address - City:DUNLAP
Mailing Address - State:IL
Mailing Address - Zip Code:61525-9473
Mailing Address - Country:US
Mailing Address - Phone:904-525-0790
Mailing Address - Fax:309-691-5639
Practice Address - Street 1:7815 N KNOXVILLE AVE STE 6
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-2016
Practice Address - Country:US
Practice Address - Phone:309-691-5514
Practice Address - Fax:309-691-5639
Is Sole Proprietor?:No
Enumeration Date:2011-09-10
Last Update Date:2011-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.293764183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist