MEDICARE: AMERICAN DRUG STORES LLC

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	332B00000X	Durable Medical Equipment & Medical Supplies
3	3336C0003X	Community/Retail Pharmacy	054-005089	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2022592	OTHER		PK

General Provider Information

NPI Number	:	1174579569
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AMERICAN DRUG STORES LLC

Provider Business Mailing Address
First Line	:	250 E PARKCENTER BLVD
Second Line	:	MAILSTOP SEC2-B
City	:	BOISE
State	:	ID
Zip	:	83706-3940
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5324 S PULASKI RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60632
Country	:	US
Telephone Number	:	773-284-7402
Fax Number	:	773-284-0366

Authorized Official
Title or Position	:	ENROLLMENT ASSISTANT MANAGER
Name	:	TIFFANY ELIOPULOS
Credential	:
Telephone Number	:	208-395-3906

Provider Enumeration Date	:	05/26/2006
Last Update Date	:	06/27/2018

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Directions to “AMERICAN DRUG STORES LLC ” Practice Location

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