1306184031 NPI number — INTEGRATED CARE PHARMACY

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306184031 NPI number — INTEGRATED CARE PHARMACY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTEGRATED CARE 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:
INTEGRATED CARE 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:
1306184031
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/07/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
222 STONE COURT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW LENOX
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60451
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
224-360-6100
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
222 STONE CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW LENOX
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60451-1598
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
224-360-6100
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/31/2013

Additional Information

Authorized Official

Authorized Official Last Name:
PANICI
Authorized Official First Name:
ANTHONY
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACIST IN CHARGE
Authorized Official Telephone Number:
224-360-6100

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  054018100 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0004X , with the licence number: 054018100 , 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: 2138272 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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