Provider Demographics
NPI:1497837009
Name:29 E MADISON CORP
Entity Type:Organization
Organization Name:29 E MADISON CORP
Other - Org Name:IVAN T MATTHEI PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:EDELHEIT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:312-263-7194
Mailing Address - Street 1:25 E WASHINGTON ST LOWR 53
Mailing Address - Street 2:LOWER LEVEL PEDWAY
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602-1736
Mailing Address - Country:US
Mailing Address - Phone:312-263-7194
Mailing Address - Fax:312-263-7636
Practice Address - Street 1:25 E WASHINGTON ST LOWR 53
Practice Address - Street 2:LOWER LEVEL PEDWAY
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-1736
Practice Address - Country:US
Practice Address - Phone:312-263-7194
Practice Address - Fax:312-263-7636
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0540135833336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6060201Medicaid
1449948OtherNCPDP PROVIDER IDENTIFICATION NUMBER
IL=========Medicaid