Provider Demographics
NPI:1235426842
Name:MUDROCH, AUDREY J (PHARM D)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:J
Last Name:MUDROCH
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 N ASHLAND AVE # 17711
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-2109
Mailing Address - Country:US
Mailing Address - Phone:773-549-5429
Mailing Address - Fax:
Practice Address - Street 1:3300 N ASHLAND AVE # 17711
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-2109
Practice Address - Country:US
Practice Address - Phone:773-549-5429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-03
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-293272183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist