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NPI Code Detail

MEDICARE: 111TH PHARMA-FAMILY

MEDICARE: 111TH PHARMA-FAMILY
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
1261QH0100XHealth Service Clinic/Center051035317IL

General Provider Information

NPI Number : 1659616175
Entity Type Code : Organization
Provider Name (Legal Business Name) : 111TH PHARMA-FAMILY
Provider Business Mailing Address
First Line : 11101 S STATE ST
Second Line :
City : CHICAGO
State : IL
Zip : 60628-4206
Country : US
Telephone Number : 708-503-9845
Fax Number :
Provider Business Practice Location Address
First Line : 11101 S STATE ST
Second Line :
City : CHICAGO
State : IL
Zip : 60628-4206
Country : US
Telephone Number : 708-503-9845
Fax Number :
Authorized Official
Title or Position : OWNER/PHARMACIST
Name : MS. ADELE VANJACKSON
Credential : RPH
Telephone Number : 708-503-9845
Provider Enumeration Date : 12/10/2012
Last Update Date : 12/10/2012

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Directions to “111TH PHARMA-FAMILY ” Practice Location

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