Provider Demographics
NPI:1114096179
Name:PLAZA PHARMACY
Entity Type:Organization
Organization Name:PLAZA PHARMACY
Other - Org Name:WEST SUBURBAN MEDICAL CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:MISS
Authorized Official - First Name:ANN
Authorized Official - Middle Name:E
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:BS PHARM
Authorized Official - Phone:708-763-1398
Mailing Address - Street 1:1 ERIE CT
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-2566
Mailing Address - Country:US
Mailing Address - Phone:708-763-1398
Mailing Address - Fax:708-383-9884
Practice Address - Street 1:1 ERIE CT
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-2566
Practice Address - Country:US
Practice Address - Phone:708-763-1398
Practice Address - Fax:708-383-9884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========004Medicaid