Healthcare Provider Details

I. General information

NPI: 1790240489
Provider Name (Legal Business Name): ST JUDE PHARMACY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2019
Last Update Date: 04/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 MADISON ST STE 114
JOLIET IL
60435-6549
US

IV. Provider business mailing address

301 MADISON ST STE 114
JOLIET IL
60435-6549
US

V. Phone/Fax

Practice location:
  • Phone: 815-900-9000
  • Fax: 815-900-5500
Mailing address:
  • Phone: 815-900-9000
  • Fax: 815-900-5500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MOHAMMED J ALAHMED
Title or Position: PHARMACIST IN CHARGE
Credential: RPH.
Phone: 815-900-9000