Provider Demographics
NPI:1295338093
Name:MEDENILLA, MAE (PHARMD)
Entity type:Individual
Prefix:DR
First Name:MAE
Middle Name:
Last Name:MEDENILLA
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 1:105 S WABASH AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60603-5711
Mailing Address - Country:US
Mailing Address - Phone:312-244-1521
Mailing Address - Fax:
Practice Address - Street 1:105 S WABASH AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60603-5711
Practice Address - Country:US
Practice Address - Phone:312-244-1521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051286380183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist