Healthcare Provider Details

I. General information

NPI: 1588906507
Provider Name (Legal Business Name): PILL SHOP PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2013
Last Update Date: 05/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3535 E NEW YORK ST STE 117
AURORA IL
60504-4466
US

IV. Provider business mailing address

3535 E NEW YORK ST STE 117
AURORA IL
60504-4466
US

V. Phone/Fax

Practice location:
  • Phone: 630-618-2048
  • Fax: 630-618-2394
Mailing address:
  • Phone: 630-618-2048
  • Fax: 630-618-2394

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number054.018224
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: ANTOINE MOURANI
Title or Position: DIRECTOR
Credential:
Phone: 312-659-3588