MEDICARE: GSK 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	3336C0003X	Community/Retail Pharmacy	054.012049	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2019825	OTHER		PK

General Provider Information

NPI Number	:	1679634497
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GSK PHARMACY INC

Provider Business Mailing Address
First Line	:	5140 W CHICAGO AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60651-2903
Country	:	US
Telephone Number	:	773-287-1078
Fax Number	:	847-699-9767

Provider Business Practice Location Address
First Line	:	5140 W CHICAGO AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60651-2903
Country	:	US
Telephone Number	:	773-287-1078
Fax Number	:	847-699-9767

Authorized Official
Title or Position	:	PRESIDENT
Name	:	PRAVIN KHATRI
Credential	:	RPH
Telephone Number	:	773-287-1078

Provider Enumeration Date	:	12/13/2006
Last Update Date	:	11/09/2015

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Directions to “GSK PHARMACY INC ” Practice Location

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