Provider Demographics
NPI:1285029439
Name:VILLA PARK PHARMACY INC
Entity Type:Organization
Organization Name:VILLA PARK PHARMACY INC
Other - Org Name:VILLA PARK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:ATIT
Authorized Official - Middle Name:
Authorized Official - Last Name:AMIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-501-0751
Mailing Address - Street 1:616 N ADDISON RD
Mailing Address - Street 2:
Mailing Address - City:VILLA PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60181-1419
Mailing Address - Country:US
Mailing Address - Phone:630-501-0751
Mailing Address - Fax:630-501-0837
Practice Address - Street 1:616 N ADDISON RD
Practice Address - Street 2:
Practice Address - City:VILLA PARK
Practice Address - State:IL
Practice Address - Zip Code:60181-1419
Practice Address - Country:US
Practice Address - Phone:630-501-0751
Practice Address - Fax:630-501-0837
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-04
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IL054-0193583336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2151236OtherPK