Healthcare Provider Details

I. General information

NPI: 1639298201
Provider Name (Legal Business Name): MIDWESTERN REGIONAL MEDICAL CENTER PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 01/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2520 ELISHA AVE
ZION IL
60099-2676
US

IV. Provider business mailing address

2520 ELISHA AVE PHARMACY
ZION IL
60099-2676
US

V. Phone/Fax

Practice location:
  • Phone: 847-872-6085
  • Fax: 847-872-6063
Mailing address:
  • Phone: 847-872-6085
  • Fax: 847-872-6063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number059003283
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: GREGG HELM
Title or Position: PHARMACY SUPERVISOR
Credential:
Phone: 847-872-6390