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General NPI Number Information
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NPI Number | 1114065976
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Entity Type | Organization
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Legal Business Name | KORLE BU PHARMACY LLC
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Dates
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Enumeration Date | 02/02/2007
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Last Update Date | 03/24/2010
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Provider Practice Location Address
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Address Line | 5517 S MICHIGAN AVE
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City | CHICAGO
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State | IL
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Zip | 60637-1012
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Country | US
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Telephone | 773-321-2656
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Fax | 773-667-9815
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Provider Business Mailing Address
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Address Line | 5 OSPREY CT
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City | STREAMWOOD
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State | IL
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Zip | 60107-2813
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PHARMICIST IN CHARGE
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Name | PRASHANT PATEL
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Credential | PHARM D
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Telephone | 847-858-4776
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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 #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 54016112
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License Number State | IL
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