Healthcare Provider Details

I. General information

NPI: 1659616175
Provider Name (Legal Business Name): 111TH PHARMA-FAMILY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2012
Last Update Date: 12/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11101 S STATE ST
CHICAGO IL
60628-4206
US

IV. Provider business mailing address

11101 S STATE ST
CHICAGO IL
60628-4206
US

V. Phone/Fax

Practice location:
  • Phone: 708-503-9845
  • Fax:
Mailing address:
  • Phone: 708-503-9845
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number051035317
License Number StateIL

VIII. Authorized Official

Name: MS. ADELE VANJACKSON
Title or Position: OWNER/PHARMACIST
Credential: RPH
Phone: 708-503-9845