Healthcare Provider Details

I. General information

NPI: 1871406207
Provider Name (Legal Business Name): MEDLYRA SUPPLY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2026
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 W DEVON AVE STE 320
CHICAGO IL
60646-4527
US

IV. Provider business mailing address

4001 W DEVON AVE STE 320
CHICAGO IL
60646-4527
US

V. Phone/Fax

Practice location:
  • Phone: 312-479-4712
  • Fax:
Mailing address:
  • Phone: 312-479-4712
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MOHAMMED ASADULLAH SHOAIB
Title or Position: OWNER
Credential:
Phone: 312-479-4712