MEDICARE: JOLIET PROFESSIONAL PHARMACY CORP.

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	332B00000X	Durable Medical Equipment & Medical Supplies	054-004174	IL
2	3336C0003X	Community/Retail Pharmacy	054-004174	IL
3	3336L0003X	Long Term Care Pharmacy

General Provider Information

NPI Number	:	1144362567
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOLIET PROFESSIONAL PHARMACY CORP.

Provider Business Mailing Address
First Line	:	2401 W JEFFERSON ST STE 200
Second Line	:
City	:	JOLIET
State	:	IL
Zip	:	60435-7830
Country	:	US
Telephone Number	:	815-725-9314
Fax Number	:	815-725-7032

Provider Business Practice Location Address
First Line	:	2401 W JEFFERSON ST STE 200
Second Line	:
City	:	JOLIET
State	:	IL
Zip	:	60435-6428
Country	:	US
Telephone Number	:	815-725-9315
Fax Number	:	815-725-3372

Authorized Official
Title or Position	:	PRESIDENT
Name	:	CHAD KODIAK
Credential	:
Telephone Number	:	815-725-9314

Provider Enumeration Date	:	02/13/2007
Last Update Date	:	06/18/2026

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