MEDICARE: BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS

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	3336C0002X	Clinic Pharmacy	054.017118	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	032-005960	OTHER	IL	STATE CONTROLLED SUBSTANC
2	1418006	OTHER	ID	NCPDP NUMBER
3	054-017118	OTHER	IL	STATE PHARMACY LICENSE
4	093-010041	OTHER	IL	STATE LICENSE NUMBER

General Provider Information

NPI Number	:	1790826352
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS

Provider Business Mailing Address
First Line	:	840 S WOOD ST
Second Line	:	ROOM 345H MC 884
City	:	CHICAGO
State	:	IL
Zip	:	60612-4325
Country	:	US
Telephone Number	:	312-355-2035
Fax Number	:	312-355-1916

Provider Business Practice Location Address
First Line	:	1220 S WOOD ST
Second Line	:	ROOM 1045 MC 884
City	:	CHICAGO
State	:	IL
Zip	:	60608-1202
Country	:	US
Telephone Number	:	312-413-1767
Fax Number	:	312-355-1916

Authorized Official
Title or Position	:	PHARMACY TECHNICIAN SPECIALIST
Name	:	MS. KRISTINE D VANKUIKEN
Credential	:	CPHT
Telephone Number	:	312-355-2035

Provider Enumeration Date	:	02/08/2007
Last Update Date	:	03/07/2023

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Directions to “BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS ” Practice Location

Language	Start Address	Practice Location

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