Provider Demographics
NPI:1154481588
Name:DU PAGE MEDICAL GROUP LTD
Entity Type:Organization
Organization Name:DU PAGE MEDICAL GROUP LTD
Other - Org Name:LAGRANGE ROAD PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:NITIKA
Authorized Official - Middle Name:
Authorized Official - Last Name:AGARWAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-432-6371
Mailing Address - Street 1:17495 LA GRANGE RD
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60487-7581
Mailing Address - Country:US
Mailing Address - Phone:708-226-7100
Mailing Address - Fax:708-226-7178
Practice Address - Street 1:17495 LA GRANGE RD
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60487-7581
Practice Address - Country:US
Practice Address - Phone:708-226-7100
Practice Address - Fax:708-226-7178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054019950333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2162402OtherPK
IL0001671073OtherBCBS OF IL
IL362757948001Medicaid