Healthcare Provider Details

I. General information

NPI: 1326111568
Provider Name (Legal Business Name): SEOUL PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 02/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3757 W LAWRENCE AVE
CHICAGO IL
60625-5712
US

IV. Provider business mailing address

3757 W LAWRENCE AVE
CHICAGO IL
60625-5712
US

V. Phone/Fax

Practice location:
  • Phone: 773-539-1234
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number054007772
License Number StateIL

VIII. Authorized Official

Name: MELANIE LEE
Title or Position: PRESIDENT
Credential: RPH
Phone: 773-359-1234