MEDICARE: ALTGELD GARDEN DRUG CO.

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	3336C0002X	Clinic Pharmacy		IL

General Provider Information

NPI Number	:	1093818148
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALTGELD GARDEN DRUG CO.

Provider Business Mailing Address
First Line	:	974 E 133RD ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60827-1428
Country	:	US
Telephone Number	:	773-264-0787
Fax Number	:	773-264-1191

Provider Business Practice Location Address
First Line	:	974 E 133RD ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60827-1428
Country	:	US
Telephone Number	:	773-264-0787
Fax Number	:	773-264-1191

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. ERSKINE ALBERT CARTWRIGHT III
Credential	:	RPH.
Telephone Number	:	773-264-0787

Provider Enumeration Date	:	09/06/2006
Last Update Date	:	08/22/2020

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