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NPI Code Detail

MEDICARE: 111TH PHARMA - FAMILY

MEDICARE: 111TH PHARMA - FAMILY
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
13336C0003XCommunity/Retail Pharmacy054018137IL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
12141774OTHERPK

General Provider Information

NPI Number : 1255415386
Entity Type Code : Organization
Provider Name (Legal Business Name) : 111TH PHARMA - FAMILY
Provider Business Mailing Address
First Line : 11101 S STATE ST
Second Line :
City : CHICAGO
State : IL
Zip : 60628-4206
Country : US
Telephone Number : 773-785-5192
Fax Number : 773-821-6970
Provider Business Practice Location Address
First Line : 11101 S STATE ST
Second Line :
City : CHICAGO
State : IL
Zip : 60628-4206
Country : US
Telephone Number : 773-785-5192
Fax Number : 773-821-6970
Authorized Official
Title or Position : PIC
Name : ADELE VANJACKSON
Credential :
Telephone Number : 773-785-5192
Provider Enumeration Date : 10/25/2006
Last Update Date : 08/27/2013

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