Provider Demographics
NPI:1356474761
Name:INGALLS PROFESSIONAL PHARMACY 4
Entity Type:Organization
Organization Name:INGALLS PROFESSIONAL PHARMACY 4
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RON
Authorized Official - Middle Name:
Authorized Official - Last Name:RUTKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-333-5388
Mailing Address - Street 1:31 W 155TH ST
Mailing Address - Street 2:
Mailing Address - City:HARVEY
Mailing Address - State:IL
Mailing Address - Zip Code:60426-3556
Mailing Address - Country:US
Mailing Address - Phone:708-589-2019
Mailing Address - Fax:
Practice Address - Street 1:31 W 155TH ST
Practice Address - Street 2:
Practice Address - City:HARVEY
Practice Address - State:IL
Practice Address - Zip Code:60426-3556
Practice Address - Country:US
Practice Address - Phone:708-589-2019
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1480639OtherNCPDP NUMBER