MEDICARE: AMERICAN DRUG STORES 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	332B00000X	Durable Medical Equipment & Medical Supplies
2	333600000X	Pharmacy
3	3336C0003X	Community/Retail Pharmacy	054-003676	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2022371	OTHER		PK

General Provider Information

NPI Number	:	1275571416
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AMERICAN DRUG STORES LLC

Provider Business Mailing Address
First Line	:	250 E PARKCENTER BLVD
Second Line	:	MAILSTOP SEC2-B
City	:	BOISE
State	:	ID
Zip	:	83706-3940
Country	:	US
Telephone Number	:	208-395-6200
Fax Number	:

Provider Business Practice Location Address
First Line	:	3531 N BROADWAY ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657
Country	:	US
Telephone Number	:	773-528-6615
Fax Number	:	773-404-6916

Authorized Official
Title or Position	:	ENROLLMENT ASSISTANT MANAGER
Name	:	TIFFANY ELIOPULOS
Credential	:
Telephone Number	:	208-395-3906

Provider Enumeration Date	:	06/02/2006
Last Update Date	:	06/28/2018

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