Provider Demographics
NPI:1649881418
Name:MO, ANNIE
Entity type:Individual
Prefix:
First Name:ANNIE
Middle Name:
Last Name:MO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2151 S WOLF RD
Mailing Address - Street 2:
Mailing Address - City:HILLSIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60162-2107
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2151 S WOLF RD
Practice Address - Street 2:
Practice Address - City:HILLSIDE
Practice Address - State:IL
Practice Address - Zip Code:60162-2107
Practice Address - Country:US
Practice Address - Phone:708-562-6105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-13
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051302631183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist