Provider Demographics
NPI:1417318072
Name:SOUTHARD, MARY (RPH)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:SOUTHARD
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 1:1006 LINDEN AVE
Mailing Address - Street 2:
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-2734
Mailing Address - Country:US
Mailing Address - Phone:612-345-0263
Mailing Address - Fax:
Practice Address - Street 1:2775 SANDERS RD
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-6110
Practice Address - Country:US
Practice Address - Phone:847-402-9400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-10
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051035853183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist