Provider Demographics
NPI:1669715967
Name:PUBENTZ, MARY (RPH)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:PUBENTZ
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 1:1701 GOLF RD
Mailing Address - Street 2:SUITE 2-1100
Mailing Address - City:ROLLING MEADOWS
Mailing Address - State:IL
Mailing Address - Zip Code:60008-4227
Mailing Address - Country:US
Mailing Address - Phone:847-635-4412
Mailing Address - Fax:847-635-5915
Practice Address - Street 1:1701 GOLF RD
Practice Address - Street 2:SUITE 2-1100
Practice Address - City:ROLLING MEADOWS
Practice Address - State:IL
Practice Address - Zip Code:60008-4227
Practice Address - Country:US
Practice Address - Phone:847-635-4412
Practice Address - Fax:847-635-5915
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-04
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-039039183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist