Provider Demographics
NPI:1114282266
Name:MARENGO COMMUNITY PHARMACY INC
Entity Type:Organization
Organization Name:MARENGO COMMUNITY PHARMACY INC
Other - Org Name:MARENGO COMMUNITY PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VIPUL
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-414-7747
Mailing Address - Street 1:20015 E GRANT HWY
Mailing Address - Street 2:
Mailing Address - City:MARENGO
Mailing Address - State:IL
Mailing Address - Zip Code:60152-8207
Mailing Address - Country:US
Mailing Address - Phone:815-568-7866
Mailing Address - Fax:818-568-7867
Practice Address - Street 1:20015 E GRANT HWY
Practice Address - Street 2:
Practice Address - City:MARENGO
Practice Address - State:IL
Practice Address - Zip Code:60152-8207
Practice Address - Country:US
Practice Address - Phone:815-568-7866
Practice Address - Fax:818-568-7867
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-05
Last Update Date:2020-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
IL54-0180443336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2137101OtherPK
2137101OtherPK
2137101OtherPK