Healthcare Provider Details

I. General information

NPI: 1447783915
Provider Name (Legal Business Name): BIENESTAR PHARMACY III, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2017
Last Update Date: 04/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2359 S WESTERN AVE SUITE 100
CHICAGO IL
60608-3837
US

IV. Provider business mailing address

2359 S WESTERN AVE SUITE 100
CHICAGO IL
60608-3837
US

V. Phone/Fax

Practice location:
  • Phone: 773-869-5200
  • Fax: 773-869-5222
Mailing address:
  • Phone: 773-869-5200
  • Fax: 773-869-5222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number054020244
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: AKIL GHOGHAWALA
Title or Position: PRESIDENT
Credential:
Phone: 773-924-6000