Healthcare Provider Details

I. General information

NPI: 1003986019
Provider Name (Legal Business Name): SHARSHON PHARMACY. INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 03/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 N. PROSPECT RD. SUITE 2
PEORIA HEIGHTS IL
61616
US

IV. Provider business mailing address

931 W GALENA BLVD
AURORA IL
60506-3751
US

V. Phone/Fax

Practice location:
  • Phone: 309-688-3684
  • Fax: 309-688-5947
Mailing address:
  • Phone: 309-688-3684
  • Fax: 390-688-5947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number054016379
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number054016379
License Number StateIL

VIII. Authorized Official

Name: WALTER SHARSHON
Title or Position: OWNER
Credential:
Phone: 630-210-5307