MEDICARE: JAMES A LOVELL FHCC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332000000X	Military/U.S. Coast Guard Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2146521	OTHER		PK

General Provider Information

NPI Number	:	1043625981
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JAMES A LOVELL FHCC

Provider Business Mailing Address
First Line	:	PO BOX 322
Second Line	:	JAMES A LOVELL FHCC
City	:	NORTH CHICAGO
State	:	IL
Zip	:	60064
Country	:	US
Telephone Number	:	224-610-4232
Fax Number	:

Provider Business Practice Location Address
First Line	:	2630 GREEN BAY RD BLDG 3452
Second Line	:
City	:	NORTH CHICAGO
State	:	IL
Zip	:	60088-3303
Country	:	US
Telephone Number	:	847-688-2772
Fax Number	:	847-688-2805

Authorized Official
Title or Position	:	CHIEF DHA PASS
Name	:	HECTOR MORALES
Credential	:
Telephone Number	:	210-536-6650

Provider Enumeration Date	:	06/30/2014
Last Update Date	:	11/24/2015

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