Provider Demographics
NPI:1083005078
Name:FULLERTON KEDZIE PROFESSIONAL PHARMACY
Entity Type:Organization
Organization Name:FULLERTON KEDZIE PROFESSIONAL PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST-IN-CHARGE
Authorized Official - Prefix:MR
Authorized Official - First Name:ETTORE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOGGETTO
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:773-278-6604
Mailing Address - Street 1:3153 W FULLERTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-2809
Mailing Address - Country:US
Mailing Address - Phone:773-278-6604
Mailing Address - Fax:773-395-4633
Practice Address - Street 1:3153 W FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-2809
Practice Address - Country:US
Practice Address - Phone:773-278-6604
Practice Address - Fax:773-395-4633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-11
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054-0071343336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL355363043002Medicaid