MEDICARE: BALLIN PHARMACY LTC INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336L0003X	Long Term Care Pharmacy	054016603	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2119620	OTHER		PK

General Provider Information

NPI Number	:	1083856561
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BALLIN PHARMACY LTC INC

Provider Business Mailing Address
First Line	:	3327 N PAULINA ST STE 1
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-1035
Country	:	US
Telephone Number	:	773-348-3009
Fax Number	:	773-348-0028

Provider Business Practice Location Address
First Line	:	3327 N PAULINA ST STE 1
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-1035
Country	:	US
Telephone Number	:	773-348-3009
Fax Number	:	773-348-0028

Authorized Official
Title or Position	:	OWNER RPH
Name	:	WM MATTSON
Credential	:
Telephone Number	:	773-348-0027

Provider Enumeration Date	:	03/31/2009
Last Update Date	:	03/18/2016

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