Provider Demographics
NPI:1225429210
Name:ACOSTA, MARTHA C
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:C
Last Name:ACOSTA
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 1:3050 N LEWIS AVE
Mailing Address - Street 2:
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60087-2231
Mailing Address - Country:US
Mailing Address - Phone:847-599-9079
Mailing Address - Fax:
Practice Address - Street 1:3050 N LEWIS AVE
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60087-2231
Practice Address - Country:US
Practice Address - Phone:847-599-9079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-11
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL049164679183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician