Provider Demographics
NPI:1700232600
Name:COGLIANESE, MARY (RPH)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:COGLIANESE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5842 110TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60415-2217
Mailing Address - Country:US
Mailing Address - Phone:708-421-9758
Mailing Address - Fax:
Practice Address - Street 1:9350 W 159TH ST
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-5500
Practice Address - Country:US
Practice Address - Phone:708-460-8212
Practice Address - Fax:708-460-5342
Is Sole Proprietor?:No
Enumeration Date:2016-05-10
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051033678183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist