Provider Demographics
NPI:1235157264
Name:SHARSHON PHARMACY, INC.
Entity Type:Organization
Organization Name:SHARSHON PHARMACY, INC.
Other - Org Name:EASY CARE PHARMACY #2
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:
Authorized Official - Last Name:SHARSHON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-210-5307
Mailing Address - Street 1:1238 W OGDEN AVE
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-2930
Mailing Address - Country:US
Mailing Address - Phone:630-210-5307
Mailing Address - Fax:630-984-5357
Practice Address - Street 1:116 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MACKINAW
Practice Address - State:IL
Practice Address - Zip Code:61755-7510
Practice Address - Country:US
Practice Address - Phone:309-359-5960
Practice Address - Fax:309-359-6930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0540189183336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
5625780001Medicare ID - Type Unspecified
IL383722072001Medicaid