Healthcare Provider Details

I. General information

NPI: 1861400905
Provider Name (Legal Business Name): ADDISON PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 01/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

414 W LAKE ST
ADDISON IL
60101-2305
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 TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

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