Provider Demographics
NPI:1427205574
Name:EVERGREEN PARK PHARMACY INC
Entity Type:Organization
Organization Name:EVERGREEN PARK PHARMACY INC
Other - Org Name:EVERGREEN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HANI
Authorized Official - Middle Name:
Authorized Official - Last Name:ABDALLAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-423-4700
Mailing Address - Street 1:2850 W 95TH ST
Mailing Address - Street 2:STE 100
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-2735
Mailing Address - Country:US
Mailing Address - Phone:708-423-4700
Mailing Address - Fax:
Practice Address - Street 1:2850 W 95TH ST
Practice Address - Street 2:STE 100
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-2735
Practice Address - Country:US
Practice Address - Phone:708-423-4700
Practice Address - Fax:708-423-4720
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-20
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IL0540164063336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2116967OtherPK