Provider Demographics
NPI:1518114750
Name:ADVENTIST GLENOAKS HOSPITAL OUTPATIENT PHARMACY
Entity Type:Organization
Organization Name:ADVENTIST GLENOAKS HOSPITAL OUTPATIENT PHARMACY
Other - Org Name:UCHICAGO MEDICINE ADVENTHEALTH PHARMACY GLENOAKS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:E
Authorized Official - Last Name:NEUMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:224-273-0516
Mailing Address - Street 1:701 WINTHROP AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60139-1405
Mailing Address - Country:US
Mailing Address - Phone:630-545-7310
Mailing Address - Fax:630-545-7315
Practice Address - Street 1:701 WINTHROP AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60139-1405
Practice Address - Country:US
Practice Address - Phone:630-545-7310
Practice Address - Fax:630-545-7315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-19
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336S0011X
IL0540174223336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2117107OtherPK
2117107OtherPK
IL=========001Medicaid