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General NPI Number Information
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NPI Number | 1992747505
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Entity Type | Organization
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Legal Business Name | PROCARE 4268 YANKEE, L.L.C.
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Dates
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Enumeration Date | 06/11/2006
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Last Update Date | 03/07/2023
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Provider Practice Location Address
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Address Line | 104 S MICHIGAN AVE SUITE 619
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City | CHICAGO
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State | IL
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Zip | 60603-5902
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Country | US
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Telephone | 312-252-7204
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Fax | 312-332-6140
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Provider Business Mailing Address
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Address Line | 104 S MICHIGAN AVE SUITE 619
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City | CHICAGO
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State | IL
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Zip | 60603-5902
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Country | US
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Telephone | 312-252-7204
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Fax | 312-332-6140
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Authorized Official
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Title or Position | MANAGER, PHARMACY ENROLLMENTS
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Name | CRISTIANA MAURICIO
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Credential |
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Telephone | 401-765-1500
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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 | 054015141
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number | 054015141
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License Number State | IL
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Taxonomy #3
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number | 054015141
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License Number State | IL
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