MEDICARE: PRO 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	333600000X	Pharmacy
2	3336C0002X	Clinic Pharmacy
3	3336C0003X	Community/Retail Pharmacy	054018191	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2139547	OTHER		PK

General Provider Information

NPI Number	:	1548503048
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRO PHARMACY INC

Provider Business Mailing Address
First Line	:	8811 S STONY ISLAND AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60617-2810
Country	:	US
Telephone Number	:	773-359-4132
Fax Number	:	773-359-4123

Provider Business Practice Location Address
First Line	:	8811 S STONY ISLAND AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60617-2810
Country	:	US
Telephone Number	:	773-359-4132
Fax Number	:	773-359-4123

Authorized Official
Title or Position	:	OWNER/PHARMACIST
Name	:	VIJAY DOSHETTY
Credential	:
Telephone Number	:	773-359-4132

Provider Enumeration Date	:	04/03/2013
Last Update Date	:	04/03/2013

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