Healthcare Provider Details

I. General information

NPI: 1720097397
Provider Name (Legal Business Name): JEAN PIERRE JEAN INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3015 W 183RD STREET
HOMEWOOD IL
60430
US

IV. Provider business mailing address

3015 W 183RD STREET
HOMEWOOD IL
60430
US

V. Phone/Fax

Practice location:
  • Phone: 708-957-6039
  • Fax: 708-957-5073
Mailing address:
  • Phone: 708-957-6039
  • Fax: 708-957-5073

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number032005145
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number054013140
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MRS. ELMA J JEAN
Title or Position: OWNER PHARMACIST
Credential:
Phone: 708-957-6039