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General NPI Number Information
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NPI Number | 1578553152
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Entity Type | Organization
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Legal Business Name | SOUTHGATE PHARMACY INC.
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Dates
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Enumeration Date | 10/25/2005
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 18659 DIXIE HWY
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City | HOMEWOOD
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State | IL
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Zip | 60430-3728
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Country | US
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Telephone | 708-798-2100
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Fax | 708-798-0686
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Provider Business Mailing Address
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Address Line | 18659 DIXIE HWY
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City | HOMEWOOD
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State | IL
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Zip | 60430-3728
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Country | US
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Telephone | 708-798-2100
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Fax | 708-798-0686
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Authorized Official
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Title or Position | MANAGER
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Name | LEONARD J SKONIECKE JR.
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Credential |
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Telephone | 708-798-2100
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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 | IL
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