MEDICARE: FORTIS PHARMACEUTICALS, 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	3336C0003X	Community/Retail Pharmacy	054.018952	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2150700	OTHER		PK

General Provider Information

NPI Number	:	1336532795
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORTIS PHARMACEUTICALS, LLC

Provider Business Mailing Address
First Line	:	7444 W WILSON AVE
Second Line	:
City	:	HARWOOD HEIGHTS
State	:	IL
Zip	:	60706-4549
Country	:	US
Telephone Number	:	847-232-7500
Fax Number	:	708-716-3625

Provider Business Practice Location Address
First Line	:	7444 W WILSON AVE
Second Line	:
City	:	HARWOOD HEIGHTS
State	:	IL
Zip	:	60706-4549
Country	:	US
Telephone Number	:	847-232-7500
Fax Number	:	708-716-3625

Authorized Official
Title or Position	:	SECRETARY
Name	:	JIGNESH GANDHI
Credential	:
Telephone Number	:	630-660-1709

Provider Enumeration Date	:	03/10/2015
Last Update Date	:	03/10/2015

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Directions to “FORTIS PHARMACEUTICALS, LLC ” Practice Location

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