MEDICARE: UKRIANIAN VILLAGE PHARMACY, 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	054015283	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1477505	OTHER	IL	NCPDP

General Provider Information

NPI Number	:	1407898067
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UKRIANIAN VILLAGE PHARMACY, INC.

Provider Business Mailing Address
First Line	:	2317 W CHICAGO AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-4723
Country	:	US
Telephone Number	:	773-235-5330
Fax Number	:	773-235-2674

Provider Business Practice Location Address
First Line	:	2317 W CHICAGO AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-4723
Country	:	US
Telephone Number	:	773-235-5330
Fax Number	:	773-235-2674

Authorized Official
Title or Position	:	GENERAL MANAGER
Name	:	MICHAEL BOGACHEK
Credential	:
Telephone Number	:	404-261-7775

Provider Enumeration Date	:	06/11/2006
Last Update Date	:	08/17/2018

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