Provider Demographics
NPI:1114295599
Name:MALLINGA, POLLY BHAMRA (DOCTOR OF PHARMACY)
Entity Type:Individual
Prefix:DR
First Name:POLLY
Middle Name:BHAMRA
Last Name:MALLINGA
Suffix:
Gender:F
Credentials:DOCTOR OF PHARMACY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2934 IMPERIAL CT
Mailing Address - Street 2:
Mailing Address - City:FLOSSMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60422-2210
Mailing Address - Country:US
Mailing Address - Phone:708-957-3505
Mailing Address - Fax:
Practice Address - Street 1:3564 RIDGE RD
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:IL
Practice Address - Zip Code:60438
Practice Address - Country:US
Practice Address - Phone:708-895-7937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-13
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.287846183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist