MEDICARE: PAUL DAVIS PHARMACY

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	54000727	IL
2	3336C0003X	Community/Retail Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1400251	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER

General Provider Information

NPI Number	:	1730190232
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAUL DAVIS PHARMACY

Provider Business Mailing Address
First Line	:	3624 W WRIGHTWOOD AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-1138
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3624 W WRIGHTWOOD AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-1138
Country	:	US
Telephone Number	:	773-489-2383
Fax Number	:	773-489-2384

Authorized Official
Title or Position	:	OWNER
Name	:	PAUL DAVIS
Credential	:
Telephone Number	:	773-489-2383

Provider Enumeration Date	:	08/10/2006
Last Update Date	:	09/11/2025

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