Provider Demographics
NPI:1114063724
Name:ADVOCATE HEALTH AND HOPSITALS CORPORATION
Entity Type:Organization
Organization Name:ADVOCATE HEALTH AND HOPSITALS CORPORATION
Other - Org Name:CHRIST HOSPITAL OUTPATIENT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY ANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:HICKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:708-684-5275
Mailing Address - Street 1:4400 W 95TH ST STE 101
Mailing Address - Street 2:DEPARTMENT OF PHARMACY
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-2655
Mailing Address - Country:US
Mailing Address - Phone:708-684-5275
Mailing Address - Fax:708-684-1712
Practice Address - Street 1:4400 W 95TH ST STE 101
Practice Address - Street 2:DEPARTMENT OF PHARMACY
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2655
Practice Address - Country:US
Practice Address - Phone:708-684-5275
Practice Address - Fax:708-684-1712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0540089723336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1431698OtherNCPDP PROVIDER IDENTIFICATION NUMBER
1431698OtherNCPDP PROVIDER IDENTIFICATION NUMBER