Healthcare Provider Details

I. General information

NPI: 1902934268
Provider Name (Legal Business Name): CARTAGENA PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 02/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 W DEVON AVE
CHICAGO IL
60660-1313
US

IV. Provider business mailing address

1505 W DEVON AVE
CHICAGO IL
60660-1313
US

V. Phone/Fax

Practice location:
  • Phone: 773-274-7885
  • Fax: 773-274-7906
Mailing address:
  • Phone: 773-274-7885
  • Fax: 773-274-7906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License NumberIL05411448
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code3336M0003X
TaxonomyManaged Care Organization Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: RONALD KIELAR
Title or Position: PHARMACIST IN CHARGE
Credential:
Phone: 773-274-7885