MEDICARE: KORLE BU PHARMACY LLC

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
2	3336C0003X	Community/Retail Pharmacy	54016112	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1480350	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1114065976
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KORLE BU PHARMACY LLC

Provider Business Mailing Address
First Line	:	5 OSPREY CT
Second Line	:
City	:	STREAMWOOD
State	:	IL
Zip	:	60107-2813
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5517 S MICHIGAN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60637-1012
Country	:	US
Telephone Number	:	773-321-2656
Fax Number	:	773-667-9815

Authorized Official
Title or Position	:	PHARMICIST IN CHARGE
Name	:	PRASHANT PATEL
Credential	:	PHARM D
Telephone Number	:	847-858-4776

Provider Enumeration Date	:	02/02/2007
Last Update Date	:	03/24/2010

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