MEDICARE: DR. MADELYN LARA PHARMD

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	183500000X	Pharmacist	051288954	IL

General Provider Information

NPI Number	:	1972631570
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MADELYN LARA PHARMD

Provider Business Mailing Address
First Line	:	905 S LOOMIS ST
Second Line	:	APT. 2
City	:	CHICAGO
State	:	IL
Zip	:	60607-4011
Country	:	US
Telephone Number	:	312-217-2171
Fax Number	:

Provider Business Practice Location Address
First Line	:	1657 W ADAMS ST
Second Line	:	UNION MEDICAL CENTER PHARMACY, 3RD FLOOR
City	:	CHICAGO
State	:	IL
Zip	:	60612-3201
Country	:	US
Telephone Number	:	312-829-1134
Fax Number	:	312-377-7983

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/02/2007
Last Update Date	:	07/08/2007

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