Provider Demographics
NPI:1578737409
Name:87TH & HARLEM CRESCENT PHARMACY INC
Entity Type:Organization
Organization Name:87TH & HARLEM CRESCENT PHARMACY INC
Other - Org Name:CRESCENT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:NADER
Authorized Official - Middle Name:
Authorized Official - Last Name:ATIEH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-598-0505
Mailing Address - Street 1:7261 W 87TH ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60455-1821
Mailing Address - Country:US
Mailing Address - Phone:708-598-0505
Mailing Address - Fax:708-598-0606
Practice Address - Street 1:7261 W 87TH ST
Practice Address - Street 2:
Practice Address - City:BRIDGEVIEW
Practice Address - State:IL
Practice Address - Zip Code:60455-1821
Practice Address - Country:US
Practice Address - Phone:708-598-0505
Practice Address - Fax:708-598-0606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-22
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0540164283336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1481883OtherNCPDP PROVIDER IDENTIFICATION NUMBER
IL262023011001Medicaid
IL=========001Medicaid