Provider Demographics
NPI:1376679902
Name:MAHURIN, NANCY
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:MAHURIN
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 1:1400 PIONEER RD APT 8
Mailing Address - Street 2:
Mailing Address - City:CREST HILL
Mailing Address - State:IL
Mailing Address - Zip Code:60435-3371
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2130 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-6622
Practice Address - Country:US
Practice Address - Phone:815-725-1102
Practice Address - Fax:815-725-7500
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL49173759183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician