1588082127 NPI number — BOLINGBROOK COMPOUNDING PHARMACY

Table of content: (NPI 1588082127)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588082127 NPI number — BOLINGBROOK COMPOUNDING PHARMACY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BOLINGBROOK COMPOUNDING 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:
BOLINGBROOK COMPOUNDING 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:
1588082127
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/01/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
402 W BOUGHTON RD STE C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOLINGBROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60440-1985
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-759-6464
Provider Business Mailing Address Fax Number:
630-759-1780

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
402 W BOUGHTON RD STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOLINGBROOK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60440-1985
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-759-6464
Provider Business Practice Location Address Fax Number:
630-759-1780
Provider Enumeration Date:
04/01/2014

Additional Information

Authorized Official

Authorized Official Last Name:
SINGLETARY
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/PHARMACIST
Authorized Official Telephone Number:
630-759-6464

Provider Taxonomy Codes

  • Taxonomy code: 3336C0004X , with the licence number:  054005594 , 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: 2144727 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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