Provider Demographics
NPI:1083769863
Name:VAN DRIEL'S DRUG STORE
Entity Type:Organization
Organization Name:VAN DRIEL'S DRUG STORE
Other - Org Name:VANDRIEL'S MEDICAL SURGICAL SUPPLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MAX
Authorized Official - Middle Name:F
Authorized Official - Last Name:ULLRICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-253-6494
Mailing Address - Street 1:319 S PINE ST
Mailing Address - Street 2:
Mailing Address - City:MT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-3117
Mailing Address - Country:US
Mailing Address - Phone:847-255-9139
Mailing Address - Fax:
Practice Address - Street 1:100 E NORTHWEST HWY
Practice Address - Street 2:
Practice Address - City:MT PROSPECT
Practice Address - State:IL
Practice Address - Zip Code:60056-3232
Practice Address - Country:US
Practice Address - Phone:847-253-6494
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0218590001Medicare NSC