=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861297749
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST JUDE PHARMACY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/15/2025
-----------------------------------------------------
Last Update Date | 02/15/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 301 MADISON ST STE 114
-----------------------------------------------------
City | JOLIET
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60435-6549
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-900-9000
-----------------------------------------------------
Fax | 815-900-5500
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 301 MADISON ST STE 114
-----------------------------------------------------
City | JOLIET
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60435-6549
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-900-9000
-----------------------------------------------------
Fax | 815-900-5500
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MOHAMMED J ALAHMED
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 815-900-9000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------