Provider Demographics
NPI:1003289281
Name:TINLEY PARK APOTHECARY LLC
Entity Type:Organization
Organization Name:TINLEY PARK APOTHECARY LLC
Other - Org Name:TINLEY PARK APOTHECARY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OMAR
Authorized Official - Middle Name:
Authorized Official - Last Name:HASSAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-778-3669
Mailing Address - Street 1:17320 OAK PARK AVE
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-3404
Mailing Address - Country:US
Mailing Address - Phone:708-778-3669
Mailing Address - Fax:708-778-3229
Practice Address - Street 1:17320 OAK PARK AVE
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-3404
Practice Address - Country:US
Practice Address - Phone:708-778-3669
Practice Address - Fax:708-778-3229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-10
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IL0540195293336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2155126OtherPK