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General NPI Number Information
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NPI Number | 1255415386
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Entity Type | Organization
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Legal Business Name | 111TH PHARMA - FAMILY
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Dates
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Enumeration Date | 10/25/2006
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Last Update Date | 08/27/2013
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Provider Practice Location Address
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Address Line | 11101 S STATE ST
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City | CHICAGO
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State | IL
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Zip | 60628-4206
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Country | US
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Telephone | 773-785-5192
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Fax | 773-821-6970
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Provider Business Mailing Address
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Address Line | 11101 S STATE ST
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City | CHICAGO
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State | IL
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Zip | 60628-4206
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Country | US
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Telephone | 773-785-5192
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Fax | 773-821-6970
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Authorized Official
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Title or Position | PIC
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Name | ADELE VANJACKSON
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Credential |
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Telephone | 773-785-5192
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 054018137
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License Number State | IL
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