Provider Demographics
NPI:1720351752
Name:MCCARTHY, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MCCARTHY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13501 CICERO AVE
Mailing Address - Street 2:
Mailing Address - City:CRESTWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60445-1934
Mailing Address - Country:US
Mailing Address - Phone:708-396-1280
Mailing Address - Fax:
Practice Address - Street 1:13501 CICERO AVE
Practice Address - Street 2:
Practice Address - City:CRESTWOOD
Practice Address - State:IL
Practice Address - Zip Code:60445-1934
Practice Address - Country:US
Practice Address - Phone:708-396-1280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-22
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.294924183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist