MEDICARE: MR. MADAN M MANOCHA RPH

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	183500000X	Pharmacist		IL

General Provider Information

NPI Number	:	1205040532
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MADAN M MANOCHA RPH

Provider Business Mailing Address
First Line	:	1005 DES PLAINES AVE
Second Line	:	APARTMENT 202
City	:	FOREST PARK
State	:	IL
Zip	:	60130-2172
Country	:	US
Telephone Number	:	708-771-4617
Fax Number	:

Provider Business Practice Location Address
First Line	:	840 S WOOD ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60612-4325
Country	:	US
Telephone Number	:	312-996-1312
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/09/2007
Last Update Date	:	07/08/2007

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