Provider Demographics
NPI:1396357125
Name:MARA, JULIE NICOLE (RPH)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:NICOLE
Last Name:MARA
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:563 S STEWART AVE
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-2859
Mailing Address - Country:US
Mailing Address - Phone:815-600-3373
Mailing Address - Fax:
Practice Address - Street 1:200 E ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:VILLA PARK
Practice Address - State:IL
Practice Address - Zip Code:60181-3500
Practice Address - Country:US
Practice Address - Phone:630-993-0869
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.299770183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist