Healthcare Provider Details

I. General information

NPI: 1073754149
Provider Name (Legal Business Name): OM RED GANESH INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2009
Last Update Date: 05/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 W DIVISION ST
CHICAGO IL
60622-2854
US

IV. Provider business mailing address

2701 W DIVISION ST
CHICAGO IL
60622-2854
US

V. Phone/Fax

Practice location:
  • Phone: 773-278-5337
  • Fax: 773-278-5365
Mailing address:
  • Phone: 773-278-5337
  • Fax: 773-278-5365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number3336C0003X
License Number StateIL

VIII. Authorized Official

Name: MR. JATIN J PATEL
Title or Position: OWNER
Credential: RPH
Phone: 773-278-5337