Provider Demographics
NPI:1043238298
Name:COOK COUNTY
Entity Type:Organization
Organization Name:COOK COUNTY
Other - Org Name:COOK COUNTY HEALTH AT BLUE ISLAND HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:GERVAISE
Authorized Official - Middle Name:
Authorized Official - Last Name:HUNTER-MORRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-293-8411
Mailing Address - Street 1:12757 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:BLUE ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60406-2155
Mailing Address - Country:US
Mailing Address - Phone:708-293-8400
Mailing Address - Fax:708-293-8408
Practice Address - Street 1:12757 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:BLUE ISLAND
Practice Address - State:IL
Practice Address - Zip Code:60406-2155
Practice Address - Country:US
Practice Address - Phone:708-293-8400
Practice Address - Fax:708-293-8408
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COOK COUNTY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-17
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0540172703336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2023252OtherPK
IL355005541070Medicaid