Provider Demographics
NPI:1497829113
Name:WEST SUBURBAN MEDICAL CENTER
Entity Type:Organization
Organization Name:WEST SUBURBAN MEDICAL CENTER
Other - Org Name:CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:E
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH, MS
Authorized Official - Phone:708-763-1398
Mailing Address - Street 1:7420 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:RIVER FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60305-1800
Mailing Address - Country:US
Mailing Address - Phone:708-763-2734
Mailing Address - Fax:708-763-2733
Practice Address - Street 1:7420 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:RIVER FOREST
Practice Address - State:IL
Practice Address - Zip Code:60305-1800
Practice Address - Country:US
Practice Address - Phone:708-763-2734
Practice Address - Fax:708-763-2733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL930133843336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========007Medicaid
IL2585360001Medicare NSC