=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316304454
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAGOM RX
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/20/2016
-----------------------------------------------------
Last Update Date | 01/20/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 114 N ABERDEEN ST UNIT 1
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60607-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-265-0144
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 114 N ABERDEEN ST UNIT 1
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60607-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-265-0144
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. KIRK HEIL
-----------------------------------------------------
Credential | PHARMD
-----------------------------------------------------
Telephone | 312-813-7928
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 054.019687
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------