Provider Demographics
NPI:1285635094
Name:200 PHARMACY INC
Entity Type:Organization
Organization Name:200 PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REG PHARMACIST AND VP
Authorized Official - Prefix:
Authorized Official - First Name:SHERMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:773-374-4550
Mailing Address - Street 1:9133 S STONY ISLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-3512
Mailing Address - Country:US
Mailing Address - Phone:773-374-4550
Mailing Address - Fax:773-374-4660
Practice Address - Street 1:9133 S STONY ISLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-3512
Practice Address - Country:US
Practice Address - Phone:773-374-4550
Practice Address - Fax:773-374-4660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-02
Last Update Date:2011-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
IL0510325043336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1445178OtherOTHER ID NUMBER
IL=========001Medicaid
1160740001Medicare NSC