MEDICARE: THORNDALE 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		IL

General Provider Information

NPI Number	:	1750561676
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THORNDALE PHARMACY INC

Provider Business Mailing Address
First Line	:	1104 W THORNDALE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60660-3516
Country	:	US
Telephone Number	:	773-561-6660
Fax Number	:	773-561-6685

Provider Business Practice Location Address
First Line	:	1104 W THORNDALE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60660-3516
Country	:	US
Telephone Number	:	773-561-6660
Fax Number	:	773-561-6685

Authorized Official
Title or Position	:	PHARMACIST
Name	:	MR. JAY L HAMMERMAN
Credential	:	RPH
Telephone Number	:	773-561-6660

Provider Enumeration Date	:	11/08/2007
Last Update Date	:	04/20/2008

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