Provider Demographics
NPI:1922779800
Name:NEGADO, MAE ALYSSA LOUDETTE (RPH)
Entity Type:Individual
Prefix:
First Name:MAE ALYSSA LOUDETTE
Middle Name:
Last Name:NEGADO
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 1:3600 LACEY RD STE 500
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-5477
Mailing Address - Country:US
Mailing Address - Phone:833-438-4494
Mailing Address - Fax:
Practice Address - Street 1:3600 LACEY RD STE 500
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-5477
Practice Address - Country:US
Practice Address - Phone:833-438-4494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-21
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX63789183500000X
IL051301029183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0000000OtherN/A