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General NPI Number Information
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NPI Number | 1083492169
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Entity Type | Organization
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Legal Business Name | PROMEDIX
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Dates
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Enumeration Date | 09/19/2023
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Last Update Date | 09/19/2023
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Provider Practice Location Address
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Address Line | 11422 S WESTERN AVE STE 101
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City | CHICAGO
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State | IL
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Zip | 60643-4120
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Country | US
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Telephone | 773-941-5968
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 734202
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City | CHICAGO
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State | IL
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Zip | 60673-4202
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Country | US
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Telephone | 773-941-5968
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Fax |
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Authorized Official
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Title or Position | BILLER
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Name | NATHAN M SMITH
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Credential |
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Telephone | 810-358-8749
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number |
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License Number State |
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