Provider Demographics
NPI:1114004538
Name:CERMAK CLINIC PHARMACY
Entity Type:Organization
Organization Name:CERMAK CLINIC PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXEC MANG
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-673-2424
Mailing Address - Street 1:6 E CERMAK RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-2108
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6 E CERMAK RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-2108
Practice Address - Country:US
Practice Address - Phone:312-791-1640
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IL054113053336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1465219OtherOTHER ID NUMBER
1465219OtherOTHER ID NUMBER-COMMERCIAL NUMBER
IL=========001Medicaid
1465219OtherOTHER ID NUMBER-COMMERCIAL NUMBER