Provider Demographics
NPI:1609266279
Name:ROSENTHAL, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:ROSENTHAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4541 N BEACON ST APT 2G
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-5545
Mailing Address - Country:US
Mailing Address - Phone:815-245-9867
Mailing Address - Fax:
Practice Address - Street 1:2112 W PETERSON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-4277
Practice Address - Country:US
Practice Address - Phone:773-761-3006
Practice Address - Fax:773-761-3413
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-03
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL049.159042183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician