Healthcare Provider Details

I. General information

NPI: 1346667656
Provider Name (Legal Business Name): AMERICAN DRUG STORES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2014
Last Update Date: 06/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

424 W DIVISION ST
CHICAGO IL
60610
US

IV. Provider business mailing address

250 E PARKCENTER BLVD MAILSTOP SEC2-B
BOISE ID
83706-3940
US

V. Phone/Fax

Practice location:
  • Phone: 312-642-2951
  • Fax: 312-642-2940
Mailing address:
  • Phone: 847-916-4463
  • Fax: 847-916-4736

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 Number054-018662
License Number StateIL

VIII. Authorized Official

Name: TIFFANY ELIOPULOS
Title or Position: ENROLLMENT ASSISTANT MANAGER
Credential:
Phone: 208-395-3906