Provider Demographics
NPI:1053465898
Name:ELGIN MENTAL HEALTH CENTER
Entity Type:Organization
Organization Name:ELGIN MENTAL HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACTING PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MOHSIN
Authorized Official - Middle Name:
Authorized Official - Last Name:ALI
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:847-742-1040
Mailing Address - Street 1:750 S STATE STREET
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-7692
Mailing Address - Country:US
Mailing Address - Phone:847-742-1040
Mailing Address - Fax:847-429-4925
Practice Address - Street 1:750 S STATE STREET
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-7692
Practice Address - Country:US
Practice Address - Phone:847-742-1040
Practice Address - Fax:847-429-4925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL059-0077003336I0012X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL144037Medicare ID - Type Unspecified