1225412786 NPI number — PRAXIS SPECIALTY PHARMACY, LLC

Table of content: (NPI 1225412786)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225412786 NPI number — PRAXIS SPECIALTY PHARMACY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRAXIS SPECIALTY PHARMACY, LLC
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:
Provider Other Organization Name Type Code:
6
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:
1225412786
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/15/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1144 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:
60301-6705
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-903-7453
Provider Business Mailing Address Fax Number:
888-958-2831

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
455 N HARLEM AVE
Provider Second Line Business Practice Location Address:
LOWER LEVEL
Provider Business Practice Location Address City Name:
OAK PARK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60301-2020
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-510-3383
Provider Business Practice Location Address Fax Number:
708-330-4467
Provider Enumeration Date:
07/15/2015

Additional Information

Authorized Official

Authorized Official Last Name:
FOLLIARD
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACIST IN CHARGE
Authorized Official Telephone Number:
888-510-3383

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  054019439 , 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)





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