Provider Demographics
NPI:1336289016
Name:UNIVERSITY OF ILLINOIS SCB PHARMACY
Entity Type:Organization
Organization Name:UNIVERSITY OF ILLINOIS SCB PHARMACY
Other - Org Name:UNIVERSITY OF ILLINOIS TAYLOR STREET EEI PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY TECHNICIAN SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:KRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-355-2035
Mailing Address - Street 1:833 S WOOD ST
Mailing Address - Street 2:ROOM 161 MC 874
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4325
Mailing Address - Country:US
Mailing Address - Phone:312-355-2035
Mailing Address - Fax:312-276-4800
Practice Address - Street 1:1009 S WOOD ST
Practice Address - Street 2:ROOM 1025 MC 874
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612
Practice Address - Country:US
Practice Address - Phone:312-996-6540
Practice Address - Fax:312-276-4800
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-08
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054.0171173336C0002X, 3336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL054-017117OtherSTATE PHARMACY LICENSE
IL032-005937OtherSTATE CONTROLLED SUBSTANC
IL1464205OtherNCPDP NUMBER
ILBU1635917OtherDEA NUMBER