1417056540 NPI number — PHARMORE DRUGS, LLC

Table of content: (NPI 1417056540)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417056540 NPI number — PHARMORE DRUGS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHARMORE DRUGS, 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:
1417056540
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/02/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3412 W TOUHY AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SKOKIE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60076-6217
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-679-7455
Provider Business Mailing Address Fax Number:
847-679-7667

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3412 W TOUHY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SKOKIE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60076-6217
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-679-7455
Provider Business Practice Location Address Fax Number:
847-679-7667
Provider Enumeration Date:
09/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PECK
Authorized Official First Name:
RANDALL
Authorized Official Middle Name:
K
Authorized Official Title or Position:
DIRECTOR OF QUALITY AND COMPLIANCE
Authorized Official Telephone Number:
847-679-7455

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X , with the licence number: 054.017037 , 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: 2023196 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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