Provider Demographics
NPI:1013035781
Name:COOK COUNTY
Entity Type:Organization
Organization Name:COOK COUNTY
Other - Org Name:FANTUS HEALTH CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:BUSKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-864-2194
Mailing Address - Street 1:1901 W HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3714
Mailing Address - Country:US
Mailing Address - Phone:312-864-6189
Mailing Address - Fax:312-864-9288
Practice Address - Street 1:1901 W HARRISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3714
Practice Address - Country:US
Practice Address - Phone:312-864-6189
Practice Address - Fax:312-864-9288
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COOK COUNTY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-27
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0540149143336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2021374OtherPK
IL=========068Medicaid