=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760483465
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NESSET PAVILION PHARMACY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/03/2005
-----------------------------------------------------
Last Update Date | 10/23/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1775 BALLARD RD
-----------------------------------------------------
City | PARK RIDGE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60068-1005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-318-2810
-----------------------------------------------------
Fax | 847-318-2795
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1775 BALLARD RD
-----------------------------------------------------
City | PARK RIDGE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60068-1005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-318-2810
-----------------------------------------------------
Fax | 847-318-2795
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACY MANAGER
-----------------------------------------------------
Name | LINDA B. GEHRT
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 847-318-2810
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------