Healthcare Provider Details

I. General information

NPI: 1861985194
Provider Name (Legal Business Name): THIRD COAST RX LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2018
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5501 S HALSTED ST STE 147
CHICAGO IL
60621-2229
US

IV. Provider business mailing address

5501 S HALSTED ST STE 147
CHICAGO IL
60621-2229
US

V. Phone/Fax

Practice location:
  • Phone: 773-359-8570
  • Fax: 773-359-8571
Mailing address:
  • Phone: 773-359-8570
  • Fax: 773-359-8571

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number054020787
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number054020787
License Number StateIL

VIII. Authorized Official

Name: AKSHAR PATEL
Title or Position: SOLE DIRECTOR
Credential:
Phone: 773-359-8570