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General NPI Number Information
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NPI Number | 1346440963
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Entity Type | Organization
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Legal Business Name | WILLOW LAKE PHARMACY INC
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Dates
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Enumeration Date | 07/22/2007
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Last Update Date | 07/22/2007
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Provider Practice Location Address
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Address Line | 303 E ARMY TRAIL RD SUITE # 108
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City | BLOOMINGDALE
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State | IL
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Zip | 60108-2169
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Country | US
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Telephone | 630-307-6260
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Fax |
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Provider Business Mailing Address
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Address Line | 303 E ARMY TRAIL RD SUITE # 108
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City | BLOOMINGDALE
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State | IL
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Zip | 60108-2169
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Country | US
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Telephone | 630-307-6260
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | ANKIT J PATEL
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Credential |
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Telephone | 630-307-6260
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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 | 54016230
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License Number State | IL
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