MEDICARE: 47TH AND VICENNES PROFESSIONAL

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	054014942	IL

General Provider Information

NPI Number	:	1942416938
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	47TH AND VICENNES PROFESSIONAL

Provider Business Mailing Address
First Line	:	504 - 506 E 47TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60653-4208
Country	:	US
Telephone Number	:	773-624-0613
Fax Number	:	773-624-0204

Provider Business Practice Location Address
First Line	:	504 E 47TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60653-4208
Country	:	US
Telephone Number	:	773-624-0613
Fax Number	:	773-624-0204

Authorized Official
Title or Position	:	PHARMCIST
Name	:	ZAROOQ SABAYO
Credential	:
Telephone Number	:	773-624-0613

Provider Enumeration Date	:	05/15/2007
Last Update Date	:	06/18/2008

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