Provider Demographics
NPI:1003986019
Name:SHARSHON PHARMACY. INC.
Entity Type:Organization
Organization Name:SHARSHON PHARMACY. INC.
Other - Org Name:SMITH EASY CARE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:
Authorized Official - Last Name:SHARSHON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-210-5307
Mailing Address - Street 1:931 W GALENA BLVD
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60506-3751
Mailing Address - Country:US
Mailing Address - Phone:309-688-3684
Mailing Address - Fax:390-688-5947
Practice Address - Street 1:4600 N. PROSPECT RD.
Practice Address - Street 2:SUITE 2
Practice Address - City:PEORIA HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:61616
Practice Address - Country:US
Practice Address - Phone:309-688-3684
Practice Address - Fax:309-688-5947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2018-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0540163793336C0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL371067969002Medicaid
IL=========001Medicaid