Provider Demographics
NPI:1144564816
Name:MARIAM PHARMACY
Entity type:Organization
Organization Name:MARIAM PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALIA
Authorized Official - Middle Name:KHALID
Authorized Official - Last Name:SHAKIR
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:773-551-5555
Mailing Address - Street 1:3514 W LAWRENCE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-5612
Mailing Address - Country:US
Mailing Address - Phone:773-551-5555
Mailing Address - Fax:
Practice Address - Street 1:3514 W LAWRENCE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-5612
Practice Address - Country:US
Practice Address - Phone:773-551-5555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-20
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051292985183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty