=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952785115
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 4 DADS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/16/2015
-----------------------------------------------------
Last Update Date | 07/16/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3365 RIDGE RD SUITE1
-----------------------------------------------------
City | LANSING
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60438-3186
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-858-2969
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3365 RIDGE RD SUITE1
-----------------------------------------------------
City | LANSING
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60438-3186
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-858-2969
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST IN CHARGE
-----------------------------------------------------
Name | JOHN SANGUEZA
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 219-308-6571
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 054018958
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------