MEDICARE: BALLIN PHARMACY LTC INC

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	333600000X	Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1483142	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1124261151
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BALLIN PHARMACY LTC INC

Provider Business Mailing Address
First Line	:	3330 N LINCOLN AVE STE B
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-1108
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3330 N LINCOLN AVE STE B
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-1108
Country	:	US
Telephone Number	:	773-348-0027
Fax Number	:	773-549-2630

Authorized Official
Title or Position	:	OWNER RPH
Name	:	WM MATTSON
Credential	:
Telephone Number	:	773-348-0027

Provider Enumeration Date	:	04/07/2009
Last Update Date	:	04/07/2009

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Directions to “BALLIN PHARMACY LTC INC ” Practice Location

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