Provider Demographics
NPI:1689967101
Name:MALLI, SAGAR (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:SAGAR
Middle Name:
Last Name:MALLI
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 N GRAND AVE W
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-2551
Mailing Address - Country:US
Mailing Address - Phone:217-523-7002
Mailing Address - Fax:217-523-7127
Practice Address - Street 1:200 N GRAND AVE W
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-2551
Practice Address - Country:US
Practice Address - Phone:217-523-7002
Practice Address - Fax:217-523-7127
Is Sole Proprietor?:No
Enumeration Date:2011-05-17
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.294203183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist