=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912063959
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BELMONT & WESTERN FARMACIA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/27/2006
-----------------------------------------------------
Last Update Date | 08/04/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2212 W. BELMONT AVE 2212 W. BELMONT AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60618-6421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-880-5544
-----------------------------------------------------
Fax | 773-880-1033
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2212 W. BELMONT AVE 2212 W. BELMONT AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60618-6421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-880-5544
-----------------------------------------------------
Fax | 773-880-1033
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/PHARMACIST
-----------------------------------------------------
Name | MR. KAMLESH P SHETH
-----------------------------------------------------
Credential | PHARMACIST
-----------------------------------------------------
Telephone | 773-880-5544
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | 054014348
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | 054-016487
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------