Provider Demographics
NPI:1407898067
Name:UKRIANIAN VILLAGE PHARMACY, INC.
Entity Type:Organization
Organization Name:UKRIANIAN VILLAGE PHARMACY, INC.
Other - Org Name:PHARMALIFE CHICAGO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BOGACHEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-261-7775
Mailing Address - Street 1:2317 W CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-4723
Mailing Address - Country:US
Mailing Address - Phone:773-235-5330
Mailing Address - Fax:773-235-2674
Practice Address - Street 1:2317 W CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-4723
Practice Address - Country:US
Practice Address - Phone:773-235-5330
Practice Address - Fax:773-235-2674
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
IL0540152833336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1477505OtherNCPDP
IL=========001Medicaid