Healthcare Provider Details

I. General information

NPI: 1104930098
Provider Name (Legal Business Name): OLYMPIA FIELDS PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 02/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

966 W 21ST ST
CHICAGO IL
60608-4511
US

IV. Provider business mailing address

966 W 21ST ST STE 104
CHICAGO IL
60608-4511
US

V. Phone/Fax

Practice location:
  • Phone: 312-226-2266
  • Fax: 312-226-9766
Mailing address:
  • Phone: 312-226-2266
  • Fax: 312-226-9766

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 TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number054015813
License Number StateIL

VIII. Authorized Official

Name: AKIL GHOGAWALA
Title or Position: PHCY MGR
Credential: PHARM.D.
Phone: 847-420-3789