MEDICARE: DR. BALDOMERO JERUSALEM SAGRADO JR. PHARMD

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	183500000X	Pharmacist	51290986	IL

General Provider Information

NPI Number	:	1295715944
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BALDOMERO JERUSALEM SAGRADO JR. PHARMD

Provider Business Mailing Address
First Line	:	3520 W AINSLIE ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-5632
Country	:	US
Telephone Number	:	671-646-7205
Fax Number	:

Provider Business Practice Location Address
First Line	:	BUILDING K-1
Second Line	:	FARENHOLT STREET
City	:	AGANA HEIGHTS
State	:	GU
Zip	:	96919
Country	:	US
Telephone Number	:	671-344-9354
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/19/2006
Last Update Date	:	07/08/2007

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