1336289016 NPI number — UNIVERSITY OF ILLINOIS SCB PHARMACY

Table of content: (NPI 1336289016)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336289016 NPI number — UNIVERSITY OF ILLINOIS SCB PHARMACY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UNIVERSITY OF ILLINOIS SCB PHARMACY
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:
UNIVERSITY OF ILLINOIS TAYLOR STREET EEI 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:
1336289016
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
833 S WOOD ST
Provider Second Line Business Mailing Address:
ROOM 161 MC 874
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60612-4325
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
312-355-2035
Provider Business Mailing Address Fax Number:
312-276-4800

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1009 S WOOD ST
Provider Second Line Business Practice Location Address:
ROOM 1025 MC 874
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-996-6540
Provider Business Practice Location Address Fax Number:
312-276-4800
Provider Enumeration Date:
02/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HAYES
Authorized Official First Name:
KRISTINE
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACY TECHNICIAN SPECIALIST
Authorized Official Telephone Number:
312-355-2035

Provider Taxonomy Codes

  • Taxonomy code: 3336C0002X , with the licence number:  054.017117 , 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: 054-017117 . This is a "STATE PHARMACY LICENSE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 032-005937 . This is a "STATE CONTROLLED SUBSTANC" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 1464205 . This is a "NCPDP NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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