Provider Demographics
NPI:1366469009
Name:HEALTH MART PHARMACY INC
Entity Type:Organization
Organization Name:HEALTH MART PHARMACY INC
Other - Org Name:HEALTH MART PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:KASS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-419-0202
Mailing Address - Street 1:81 S MILWAUKEE AVE
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:IL
Mailing Address - Zip Code:60090-3120
Mailing Address - Country:US
Mailing Address - Phone:847-419-0202
Mailing Address - Fax:847-419-0222
Practice Address - Street 1:81 S MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:IL
Practice Address - Zip Code:60090-3120
Practice Address - Country:US
Practice Address - Phone:847-419-0202
Practice Address - Fax:847-419-0222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0540136673336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1467819OtherNCPDP PROVIDER IDENTIFICATION NUMBER
IL=========001Medicaid
IL=========001Medicaid