Provider Demographics
NPI:1114002136
Name:WALTER LAGESTEE INCORPORATED
Entity Type:Organization
Organization Name:WALTER LAGESTEE INCORPORATED
Other - Org Name:WALT'S PHARMACY #2
Other - Org Type:Doing Business As
Authorized Official - Title/Position:THIRD PARTY COORDINATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:J
Authorized Official - Last Name:EGAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:708-957-2974
Mailing Address - Street 1:2345 183RD ST
Mailing Address - Street 2:
Mailing Address - City:HOMEWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60430-3140
Mailing Address - Country:US
Mailing Address - Phone:708-957-2974
Mailing Address - Fax:708-957-9331
Practice Address - Street 1:2345 183RD ST
Practice Address - Street 2:
Practice Address - City:HOMEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60430-3140
Practice Address - Country:US
Practice Address - Phone:708-957-2974
Practice Address - Fax:708-957-9331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054-119073336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========004Medicaid
IL=========004Medicaid