Provider Demographics
NPI:1578096749
Name:MIDWEST SPECIALTY PHARMACY LLC
Entity Type:Organization
Organization Name:MIDWEST SPECIALTY PHARMACY LLC
Other - Org Name:MIDWEST SPECIALTY PHARMACY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:FEDJA
Authorized Official - Middle Name:
Authorized Official - Last Name:TEMIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-690-4585
Mailing Address - Street 1:712 N DEARBORN ST
Mailing Address - Street 2:STE. 3A
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-3846
Mailing Address - Country:US
Mailing Address - Phone:312-690-4585
Mailing Address - Fax:312-690-4575
Practice Address - Street 1:712 N DEARBORN ST
Practice Address - Street 2:STE. 3A
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-3846
Practice Address - Country:US
Practice Address - Phone:312-690-4585
Practice Address - Fax:312-690-4575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-05
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
IL0540202973336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2168676OtherPK