Provider Demographics
NPI:1801957782
Name:CONLIN, MARK (RPH)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:CONLIN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12035 LANCASTER CT
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60467-1143
Mailing Address - Country:US
Mailing Address - Phone:708-301-3305
Mailing Address - Fax:708-301-6529
Practice Address - Street 1:1615 N STATE ROUTE 50
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-9324
Practice Address - Country:US
Practice Address - Phone:815-933-1777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2021-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051033743183500000X
IN26023410A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL362590334001Medicaid
IL1412232OtherNABP
IL362590334001Medicaid