=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902417207
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IPACK PHARMACY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2020
-----------------------------------------------------
Last Update Date | 10/07/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17000 W NORTH AVE STE 108W
-----------------------------------------------------
City | BROOKFIELD
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53005-4423
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-649-3900
-----------------------------------------------------
Fax | 262-649-3076
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17000 W NORTH AVE STE 108W
-----------------------------------------------------
City | BROOKFIELD
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53005-4423
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-649-3900
-----------------------------------------------------
Fax | 262-649-3076
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | SUNNY DINESHKUMAR PATEL
-----------------------------------------------------
Credential | PHARMACIST
-----------------------------------------------------
Telephone | 262-649-3900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------