MEDICARE: GOLF MILL PHARMACY AND MEDICAL SUPPLY 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	332B00000X	Durable Medical Equipment & Medical Supplies
2	3336C0003X	Community/Retail Pharmacy	054016631	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2119936	OTHER		PK

General Provider Information

NPI Number	:	1144464876
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOLF MILL PHARMACY AND MEDICAL SUPPLY INC

Provider Business Mailing Address
First Line	:	8334 KARLOV AVE
Second Line	:
City	:	SKOKIE
State	:	IL
Zip	:	60076-2738
Country	:	US
Telephone Number	:	847-803-3340
Fax Number	:

Provider Business Practice Location Address
First Line	:	8941 W GOLF RD
Second Line	:
City	:	NILES
State	:	IL
Zip	:	60714-5812
Country	:	US
Telephone Number	:	847-803-3340
Fax Number	:	847-803-3342

Authorized Official
Title or Position	:	PIC
Name	:	VLADIMIR DEYSKI
Credential	:	PHARM. D.
Telephone Number	:	847-803-3340

Provider Enumeration Date	:	04/24/2009
Last Update Date	:	04/15/2016

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