Healthcare Provider Details

I. General information

NPI: 1861413189
Provider Name (Legal Business Name): FAGEN PHARMACY 15
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11112 FRONT ST
MOKENA IL
60448-1562
US

IV. Provider business mailing address

FAGEN PHARMACY PO BOX 9830
SALT LAKE CITY UT
84109-9913
US

V. Phone/Fax

Practice location:
  • Phone: 708-479-9333
  • Fax: 708-479-5633
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number54014975
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: LARRY WOJCIK
Title or Position: 3RD PARTY COORD
Credential:
Phone: 219-987-6468