Provider Demographics
NPI:1568748861
Name:WAYNE, MARK A (RPH)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:WAYNE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 PLAINFIELD RD
Mailing Address - Street 2:
Mailing Address - City:WILLOWBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60527-5341
Mailing Address - Country:US
Mailing Address - Phone:630-789-1797
Mailing Address - Fax:630-789-2463
Practice Address - Street 1:501 PLAINFIELD RD
Practice Address - Street 2:
Practice Address - City:WILLOWBROOK
Practice Address - State:IL
Practice Address - Zip Code:60527-5341
Practice Address - Country:US
Practice Address - Phone:630-789-1797
Practice Address - Fax:630-789-2463
Is Sole Proprietor?:No
Enumeration Date:2011-10-31
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-0359091835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy