MEDICARE: LUNA PHARMACY AT MADISON 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	3336C0003X	Community/Retail Pharmacy

General Provider Information

NPI Number	:	1245703982
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LUNA PHARMACY AT MADISON LLC

Provider Business Mailing Address
First Line	:	3171 W MADISON ST STE 2
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60612-1809
Country	:	US
Telephone Number	:	773-435-9905
Fax Number	:	773-340-4435

Provider Business Practice Location Address
First Line	:	3171 W MADISON ST STE 2
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60612-1809
Country	:	US
Telephone Number	:	773-435-9905
Fax Number	:	773-340-4435

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MOHAMMAD KHAMIS
Credential	:
Telephone Number	:	773-353-5047

Provider Enumeration Date	:	01/04/2019
Last Update Date	:	01/04/2019

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