Provider Demographics
NPI:1235303983
Name:HENDRICKSON, MARY L (RPH,MBA)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:L
Last Name:HENDRICKSON
Suffix:
Gender:F
Credentials:RPH,MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6101 N 64TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53218-1543
Mailing Address - Country:US
Mailing Address - Phone:262-649-6914
Mailing Address - Fax:
Practice Address - Street 1:6101 N 64TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53218-1543
Practice Address - Country:US
Practice Address - Phone:262-649-6914
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-14
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11545183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist