Provider Demographics
NPI:1588054258
Name:LOPEZ, MARI
Entity type:Individual
Prefix:
First Name:MARI
Middle Name:
Last Name:LOPEZ
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 1:2954 W WAVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-4631
Mailing Address - Country:US
Mailing Address - Phone:773-593-5357
Mailing Address - Fax:
Practice Address - Street 1:2939 W ADDISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-4635
Practice Address - Country:US
Practice Address - Phone:773-604-7681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-02
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL049.204428183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician