1245441815 NPI number — THOREK MEMORIAL HOSPITAL

Table of content: (NPI 1245441815)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245441815 NPI number — THOREK MEMORIAL HOSPITAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THOREK MEMORIAL HOSPITAL
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
THOREK HOSPITAL OUTPATIENT PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245441815
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/07/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
THOREK HOSPITAL OUTPATIENT PHARMACY
Provider Second Line Business Mailing Address:
850 W IRVING PARK RD
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60613
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-975-3235
Provider Business Mailing Address Fax Number:
773-975-3238

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
850 W IRVING PARK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60613-3077
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-975-3235
Provider Business Practice Location Address Fax Number:
773-975-3238
Provider Enumeration Date:
05/25/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DAVID
Authorized Official First Name:
JAY
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACIST IN CHARGE
Authorized Official Telephone Number:
773-975-3235

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  054017097 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3660000985401 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1432981 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".