Provider Demographics
NPI:1407022247
Name:MEDCENTRIX INC
Entity Type:Organization
Organization Name:MEDCENTRIX INC
Other - Org Name:INGALLS PRO PHARM 3
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:J
Authorized Official - Last Name:RUTKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:708-915-8453
Mailing Address - Street 1:19550 GOVERNORS HWY
Mailing Address - Street 2:
Mailing Address - City:FLOSSMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60422-2125
Mailing Address - Country:US
Mailing Address - Phone:708-915-8453
Mailing Address - Fax:708-915-8579
Practice Address - Street 1:19550 GOVERNORS HWY
Practice Address - Street 2:
Practice Address - City:FLOSSMOOR
Practice Address - State:IL
Practice Address - Zip Code:60422-2125
Practice Address - Country:US
Practice Address - Phone:708-915-8453
Practice Address - Fax:708-915-8579
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-01
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0540155493336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========6042201OtherHFS PAYEE NUMBER
IL=========003Medicaid