=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104129006
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAL'S MEDICAL ENTERPRISES, SERVICE CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/15/2010
-----------------------------------------------------
Last Update Date | 01/26/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 515 W TAFT DR
-----------------------------------------------------
City | SOUTH HOLLAND
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60473-2030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-333-6660
-----------------------------------------------------
Fax | 580-510-0514
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2032
-----------------------------------------------------
City | DES PLAINES
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60017-2032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-333-6660
-----------------------------------------------------
Fax | 580-510-0514
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. ERIC V HEARN SR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 708-333-6660
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | 054016335
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------