Healthcare Provider Details

I. General information

NPI: 1255415386
Provider Name (Legal Business Name): 111TH PHARMA - FAMILY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 08/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11101 S STATE ST
CHICAGO IL
60628-4206
US

IV. Provider business mailing address

11101 S STATE ST
CHICAGO IL
60628-4206
US

V. Phone/Fax

Practice location:
  • Phone: 773-785-5192
  • Fax: 773-821-6970
Mailing address:
  • Phone: 773-785-5192
  • Fax: 773-821-6970

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number054018137
License Number StateIL

VIII. Authorized Official

Name: ADELE VANJACKSON
Title or Position: PIC
Credential:
Phone: 773-785-5192