Provider Demographics
NPI:1205854866
Name:OAK FOREST HOSPITAL PHARMACY
Entity Type:Organization
Organization Name:OAK FOREST HOSPITAL PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:708-633-4437
Mailing Address - Street 1:15900 CICERO AVENUE
Mailing Address - Street 2:
Mailing Address - City:OAK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60452-4006
Mailing Address - Country:US
Mailing Address - Phone:708-633-4437
Mailing Address - Fax:708-633-4442
Practice Address - Street 1:15900 CICERO AVENUE
Practice Address - Street 2:
Practice Address - City:OAK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60452-4006
Practice Address - Country:US
Practice Address - Phone:708-633-4437
Practice Address - Fax:708-633-4442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILAJ41001713336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========070Medicaid