Provider Demographics
NPI:1043591753
Name:NOVAK, CAROL CASSIDY (RPH)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:CASSIDY
Last Name:NOVAK
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 1:1700 LARKIN AVE
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-5947
Mailing Address - Country:US
Mailing Address - Phone:847-695-1158
Mailing Address - Fax:
Practice Address - Street 1:1700 LARKIN AVE
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-5947
Practice Address - Country:US
Practice Address - Phone:847-695-1158
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-08
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.037840183500000X
MI5302026434183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist