Provider Demographics
NPI:1447783915
Name:BIENESTAR PHARMACY III, INC
Entity Type:Organization
Organization Name:BIENESTAR PHARMACY III, INC
Other - Org Name:BIENESTAR PHARMACY III, INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AKIL
Authorized Official - Middle Name:
Authorized Official - Last Name:GHOGHAWALA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-924-6000
Mailing Address - Street 1:2359 S WESTERN AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-3837
Mailing Address - Country:US
Mailing Address - Phone:773-869-5200
Mailing Address - Fax:773-869-5222
Practice Address - Street 1:2359 S WESTERN AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-3837
Practice Address - Country:US
Practice Address - Phone:773-869-5200
Practice Address - Fax:773-869-5222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-11
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054020244333600000X
3336C0002X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2168803OtherPK