Provider Demographics
NPI:1396813408
Name:VIVEK PHARMACY, INC.
Entity Type:Organization
Organization Name:VIVEK PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BANKIM
Authorized Official - Middle Name:
Authorized Official - Last Name:DESAI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-548-3133
Mailing Address - Street 1:300 E PERSHING RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60653-2204
Mailing Address - Country:US
Mailing Address - Phone:773-548-3133
Mailing Address - Fax:773-751-5099
Practice Address - Street 1:300 E PERSHING RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60653-2204
Practice Address - Country:US
Practice Address - Phone:773-548-3133
Practice Address - Fax:773-913-2335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0540112683336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1462908OtherNABP NUMBER
IL=========001Medicaid
IL=========001Medicaid