=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073078325
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STAYWELL PHARMACY CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2019
-----------------------------------------------------
Last Update Date | 05/08/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 912 E NORTHWEST HWY UNIT C-131
-----------------------------------------------------
City | PALATINE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60074-6506
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-942-3110
-----------------------------------------------------
Fax | 847-496-5437
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 912 E NORTHWEST HWY
-----------------------------------------------------
City | PALATINE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60074-6506
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-496-5559
-----------------------------------------------------
Fax | 847-496-5437
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT
-----------------------------------------------------
Name | MR. SADATHULLA SHAREEF
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 516-859-4292
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------