Provider Demographics
NPI:1447240668
Name:KLIETHERMES, MARK JOSEPH SR (RPH, MBA)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:JOSEPH
Last Name:KLIETHERMES
Suffix:SR
Gender:M
Credentials:RPH, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 S KENMORE AVE
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-3518
Mailing Address - Country:US
Mailing Address - Phone:630-886-5588
Mailing Address - Fax:630-832-5966
Practice Address - Street 1:3300 OAK PARK AVE
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-3433
Practice Address - Country:US
Practice Address - Phone:708-783-2411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-034080183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL051-034080OtherSTATE PHARMACY LICENSE