Provider Demographics
NPI:1285660910
Name:SIMSUM INC
Entity Type:Organization
Organization Name:SIMSUM INC
Other - Org Name:MEDICAL ARTS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHCY MGR
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:SMULKAITIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-758-3100
Mailing Address - Street 1:625 BETHANY RD STE 2
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-4908
Mailing Address - Country:US
Mailing Address - Phone:815-758-3100
Mailing Address - Fax:815-758-3105
Practice Address - Street 1:625 BETHANY RD STE 2
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-4908
Practice Address - Country:US
Practice Address - Phone:815-758-3100
Practice Address - Fax:815-758-3105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2010-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IL0540349233336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1475842OtherNCPDP PROVIDER IDENTIFICATION NUMBER
1475842OtherNCPDP PROVIDER IDENTIFICATION NUMBER