Provider Demographics
NPI:1710335682
Name:HENRY, MARK MICHAEL (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:MICHAEL
Last Name:HENRY
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 1:1414 N DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:60450-1583
Mailing Address - Country:US
Mailing Address - Phone:815-941-2353
Mailing Address - Fax:
Practice Address - Street 1:1414 N DIVISION ST
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:IL
Practice Address - Zip Code:60450-1583
Practice Address - Country:US
Practice Address - Phone:815-941-2353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-01
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.298927183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist