Provider Demographics
NPI:1407954431
Name:SHARSHON PHARMACY, INC.
Entity Type:Organization
Organization Name:SHARSHON PHARMACY, INC.
Other - Org Name:NORTHSIDE REXALL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:
Authorized Official - Last Name:SHARSHON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:630-210-5307
Mailing Address - Street 1:931 W GALENA BLVD
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60506-3751
Mailing Address - Country:US
Mailing Address - Phone:630-210-5307
Mailing Address - Fax:630-984-5357
Practice Address - Street 1:201 N STATE ST
Practice Address - Street 2:
Practice Address - City:GENESEO
Practice Address - State:IL
Practice Address - Zip Code:61254-1236
Practice Address - Country:US
Practice Address - Phone:309-944-2442
Practice Address - Fax:309-944-4588
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IL0540110883336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2022550OtherPK
IL362755366001Medicaid
IL=========001Medicaid
IL=========001Medicaid