Provider Demographics
NPI:1679853113
Name:FIDLER, MARY EMILY (PHARMD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:EMILY
Last Name:FIDLER
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1128 TYRELL AVE
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-1647
Mailing Address - Country:US
Mailing Address - Phone:847-624-6279
Mailing Address - Fax:
Practice Address - Street 1:9150 SKOKIE BLVD
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-1785
Practice Address - Country:US
Practice Address - Phone:847-673-8063
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-27
Last Update Date:2011-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051293068183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist