Provider Demographics
NPI:1619252103
Name:KOMPERDA, MARY ANN
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:KOMPERDA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10502 WILDFLOWER RD
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-7444
Mailing Address - Country:US
Mailing Address - Phone:708-460-4516
Mailing Address - Fax:
Practice Address - Street 1:5414 S ARCHER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60638-3002
Practice Address - Country:US
Practice Address - Phone:773-581-1664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-15
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.034992183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist