1053322552 NPI number — PETERSONS PERSCRIPTION PHARMACY INC

Table of content: (NPI 1053322552)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053322552 NPI number — PETERSONS PERSCRIPTION PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PETERSONS PERSCRIPTION PHARMACY INC
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:
PETERSONS PRESCRIPTION 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:
1053322552
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/31/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
715 LAKE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAK PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60301-1467
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-848-5020
Provider Business Mailing Address Fax Number:
708-848-5022

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
715 LAKE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OAK PARK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60301-1467
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-848-5020
Provider Business Practice Location Address Fax Number:
708-848-5022
Provider Enumeration Date:
08/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ELICH
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
708-868-5020

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 054010011 , 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: 367728439001 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1459800 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




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