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General NPI Number Information
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NPI Number | 1104930098
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Entity Type | Organization
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Legal Business Name | OLYMPIA FIELDS PHARMACY INC
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Dates
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Enumeration Date | 08/18/2006
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Last Update Date | 02/21/2017
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Provider Practice Location Address
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Address Line | 966 W 21ST ST
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City | CHICAGO
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State | IL
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Zip | 60608-4511
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Country | US
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Telephone | 312-226-2266
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Fax | 312-226-9766
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Provider Business Mailing Address
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Address Line | 966 W 21ST ST STE 104
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City | CHICAGO
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State | IL
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Zip | 60608-4511
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Country | US
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Telephone | 312-226-2266
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Fax | 312-226-9766
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Authorized Official
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Title or Position | PHCY MGR
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Name | AKIL GHOGAWALA
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Credential | PHARM.D.
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Telephone | 847-420-3789
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 3336C0002X
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Taxonomy Name | Clinic Pharmacy
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 054015813
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License Number State | IL
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