Healthcare Provider Details

I. General information

NPI: 1326457565
Provider Name (Legal Business Name): ADDISON PHARMACY & MEDICAL SUPPLY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2014
Last Update Date: 01/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

441 W LAKE ST
ADDISON IL
60101-2316
US

IV. Provider business mailing address

414 W LAKE ST
ADDISON IL
60101-2305
US

V. Phone/Fax

Practice location:
  • Phone: 630-543-0988
  • Fax: 630-543-0918
Mailing address:
  • Phone: 630-543-0988
  • Fax: 630-543-0918

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1475791
Identifier TypeOTHER
Identifier StateIL
Identifier IssuerNABP

VIII. Authorized Official

Name: MRS. KERUL MEHTA
Title or Position: PHARMACY MANAGER
Credential: RPH
Phone: 630-543-0988