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General NPI Number Information
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NPI Number | 1891882080
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Entity Type | Organization
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Legal Business Name | CHURCH ST PHARM INC
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Dates
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Enumeration Date | 10/07/2006
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Last Update Date | 10/28/2009
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Provider Practice Location Address
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Address Line | 9669 KENTON AVE
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City | SKOKIE
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State | IL
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Zip | 60076-1266
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Country | US
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Telephone | 847-674-5882
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Fax | 847-674-9824
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Provider Business Mailing Address
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Address Line | 9669 KENTON AVE
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City | SKOKIE
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State | IL
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Zip | 60076-1266
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CHIEF PHARMACIST
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Name | MARK JACOBS
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Credential | RPH
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Telephone | 847-674-5882
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number | 54009433
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License Number State | IL
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