Provider Demographics
NPI:1447390125
Name:BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS
Entity Type:Organization
Organization Name:BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS
Other - Org Name:UNIVERSITY OF ILLINOIS - UNIVERSITY VILLAGE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY TECHNICIAN SPECIALIST
Authorized Official - Prefix:MS
Authorized Official - First Name:KRISTINE
Authorized Official - Middle Name:D
Authorized Official - Last Name:VANKUIKEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-355-2035
Mailing Address - Street 1:840 S WOOD ST
Mailing Address - Street 2:ROOM 345H MC 884
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4325
Mailing Address - Country:US
Mailing Address - Phone:312-355-2035
Mailing Address - Fax:312-355-1916
Practice Address - Street 1:722 W MAXWELL ST
Practice Address - Street 2:ROOM 205 MC 184
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-5002
Practice Address - Country:US
Practice Address - Phone:312-355-2345
Practice Address - Fax:312-355-1916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054.0172533336C0002X
IL093-0134743336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1479876OtherNCPDP NUMBER
IL054-017253OtherSTATE PHARMACY LICENSE
IL032-008745OtherSTATE CONTROLLED SUBSTANC
IL032-008745OtherSTATE CONTROLLED SUBSTANC