MEDICARE: VICS 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	3336C0003X	Community/Retail Pharmacy

General Provider Information

NPI Number	:	1992138226
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VICS PHARMACY INC

Provider Business Mailing Address
First Line	:	1313 W MORSE AVE UNIT B
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60626-3521
Country	:	US
Telephone Number	:	773-764-0044
Fax Number	:	773-764-1126

Provider Business Practice Location Address
First Line	:	1313 W MORSE AVE UNIT B
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60626-3521
Country	:	US
Telephone Number	:	773-764-0044
Fax Number	:	773-764-1126

Authorized Official
Title or Position	:	PRESIDENT
Name	:	RICHARD MBACHU
Credential	:
Telephone Number	:	773-454-3392

Provider Enumeration Date	:	08/09/2013
Last Update Date	:	08/09/2013

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