Provider Demographics
NPI:1326495623
Name:ZZZ
Entity Type:Organization
Organization Name:ZZZ
Other - Org Name:ZZZ
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
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 1:931 W GALENA BLVD
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60506-3751
Mailing Address - Country:US
Mailing Address - Phone:309-244-7115
Mailing Address - Fax:
Practice Address - Street 1:402 PINE ST
Practice Address - Street 2:
Practice Address - City:DELAVAN
Practice Address - State:IL
Practice Address - Zip Code:61734-7575
Practice Address - Country:US
Practice Address - Phone:309-244-7115
Practice Address - Fax:309-244-7151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-17
Last Update Date:2016-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3423423423333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy