Provider Demographics
NPI:1316004385
Name:MA, MICHAEL (PHARMD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MA
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 25TH AVE
Mailing Address - Street 2:
Mailing Address - City:BELLWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60104-1517
Mailing Address - Country:US
Mailing Address - Phone:708-362-9860
Mailing Address - Fax:847-291-8492
Practice Address - Street 1:707 SKOKIE BLVD
Practice Address - Street 2:SUITE 600
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-2857
Practice Address - Country:US
Practice Address - Phone:708-362-9860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA555761835N0905X
IL051288705183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835N0905XPharmacy Service ProvidersPharmacistNuclear