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General NPI Number Information
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NPI Number | 1538174149
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Entity Type | Organization
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Legal Business Name | CONNEYS ELM STREET PHARMACY INC
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Dates
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Enumeration Date | 07/30/2006
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Last Update Date | 12/06/2011
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Provider Practice Location Address
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Address Line | 736 ELM ST
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City | WINNETKA
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State | IL
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Zip | 60093-2506
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Country | US
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Telephone | 847-446-3335
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Fax | 847-446-1574
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Provider Business Mailing Address
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Address Line | 736 ELM ST
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City | WINNETKA
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State | IL
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Zip | 60093-2506
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Country | US
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Telephone | 847-446-0032
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Fax | 847-446-1574
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Authorized Official
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Title or Position | PHARMACIST AND OWNER
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Name | MR. MARK JACOBS
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Credential |
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Telephone | 847-446-0032
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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 #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 054013973
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License Number State | IL
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