MEDICARE: EDISON MEDICAL 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	054009337	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2020547	OTHER		PK

General Provider Information

NPI Number	:	1821166067
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EDISON MEDICAL PHARMACY INC

Provider Business Mailing Address
First Line	:	4240 W MADISON ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60624-2288
Country	:	US
Telephone Number	:	773-533-2535
Fax Number	:	773-533-2535

Provider Business Practice Location Address
First Line	:	4240 W MADISON ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60624-2288
Country	:	US
Telephone Number	:	773-533-2535
Fax Number	:	773-533-2535

Authorized Official
Title or Position	:	RPHOWNER
Name	:	PRAVINCHANDRA SHAH
Credential	:	RPH
Telephone Number	:	773-533-2535

Provider Enumeration Date	:	12/04/2006
Last Update Date	:	03/13/2015

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Directions to “EDISON MEDICAL PHARMACY INC ” Practice Location

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