Provider Demographics
NPI:1659037141
Name:HAFZALLA, MARIAN I
Entity Type:Individual
Prefix:
First Name:MARIAN
Middle Name:I
Last Name:HAFZALLA
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 1:1099 W ARMY TRAIL RD
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:IL
Mailing Address - Zip Code:60103-3001
Mailing Address - Country:US
Mailing Address - Phone:630-372-3120
Mailing Address - Fax:
Practice Address - Street 1:1099 W ARMY TRAIL RD
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:IL
Practice Address - Zip Code:60103-3001
Practice Address - Country:US
Practice Address - Phone:630-372-3120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-10
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.304397183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist