=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740230879
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELGIN PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2006
-----------------------------------------------------
Last Update Date | 06/02/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 417 DUNDEE AVE
-----------------------------------------------------
City | ELGIN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60120-3830
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-488-9273
-----------------------------------------------------
Fax | 847-488-9278
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 417 DUNDEE AVE
-----------------------------------------------------
City | ELGIN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60120-3830
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-488-9273
-----------------------------------------------------
Fax | 847-488-9278
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST IN CHARGE
-----------------------------------------------------
Name | MR. ARVIND SURTI
-----------------------------------------------------
Credential | R.PH
-----------------------------------------------------
Telephone | 847-488-9273
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 054015787
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------