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General NPI Number Information
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NPI Number | 1659616175
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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 | 12/10/2012
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Last Update Date | 12/10/2012
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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 | 708-503-9845
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Fax |
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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 | 708-503-9845
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Fax |
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Authorized Official
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Title or Position | OWNER/PHARMACIST
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Name | MS. ADELE VANJACKSON
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Credential | RPH
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Telephone | 708-503-9845
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number | 051035317
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License Number State | IL
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