Provider Demographics
NPI:1346787058
Name:BELMONT & WESTERN FARMACIA LLC
Entity Type:Organization
Organization Name:BELMONT & WESTERN FARMACIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:KAMLESH
Authorized Official - Middle Name:P
Authorized Official - Last Name:SHETH
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:773-880-5544
Mailing Address - Street 1:2212 W BELMONT AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-6421
Mailing Address - Country:US
Mailing Address - Phone:773-880-5544
Mailing Address - Fax:773-880-1033
Practice Address - Street 1:2212 W BELMONT AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-6421
Practice Address - Country:US
Practice Address - Phone:773-880-5544
Practice Address - Fax:773-880-1033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-20
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-0331553336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid