Provider Demographics
NPI:1447544762
Name:FREEHAUF, MARY JANE (RPH)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:JANE
Last Name:FREEHAUF
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:JANE
Other - Last Name:BRUMMEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:1400 E IRELAND RD
Mailing Address - Street 2:T-1902
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46614-3452
Mailing Address - Country:US
Mailing Address - Phone:574-231-8258
Mailing Address - Fax:574-231-8258
Practice Address - Street 1:1400 E IRELAND RD
Practice Address - Street 2:T-1902
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46614-3452
Practice Address - Country:US
Practice Address - Phone:574-231-8258
Practice Address - Fax:574-231-8258
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-03
Last Update Date:2011-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26018158A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist