Healthcare Provider Details

I. General information

NPI: 1861985194
Provider Name (Legal Business Name): FOUNDER PROJECT RX, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2018
Last Update Date: 06/19/2023
Certification Date: 06/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5501 S HALSTED STREET SUITE #147
CHICAGO IL
60621-2229
US

IV. Provider business mailing address

1620 W NORTHWEST HWY SUITE 100
GRAPEVINE TX
76051-3219
US

V. Phone/Fax

Practice location:
  • Phone: 773-359-8570
  • Fax: 773-359-8571
Mailing address:
  • Phone: 817-572-0009
  • Fax: 817-572-0221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: NICKY L OTTS
Title or Position: PRESIDENT, MANAGING OFFICER
Credential:
Phone: 817-239-6516