MEDICARE: ZZZ

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	3423423423	AL

General Provider Information

NPI Number	:	1326495623
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ZZZ

Provider Business Mailing Address
First Line	:	931 W GALENA BLVD
Second Line	:
City	:	AURORA
State	:	IL
Zip	:	60506-3751
Country	:	US
Telephone Number	:	309-244-7115
Fax Number	:

Provider Business Practice Location Address
First Line	:	402 PINE ST
Second Line	:
City	:	DELAVAN
State	:	IL
Zip	:	61734-7575
Country	:	US
Telephone Number	:	309-244-7115
Fax Number	:	309-244-7151

Authorized Official
Title or Position	:	OWNER
Name	:	MR. WALTER SHARSHON
Credential	:
Telephone Number	:	630-210-5307

Provider Enumeration Date	:	05/17/2016
Last Update Date	:	05/17/2016

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Directions to “ZZZ ” Practice Location

Language	Start Address	Practice Location

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