Provider Demographics
NPI:1609806983
Name:MARTIN AVENUE PHARMACY INC
Entity Type:Organization
Organization Name:MARTIN AVENUE PHARMACY INC
Other - Org Name:MARTIN AVENUE PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:MARKS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:630-355-6400
Mailing Address - Street 1:1247 RICKERT DR
Mailing Address - Street 2:STE 100
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60540-1008
Mailing Address - Country:US
Mailing Address - Phone:630-355-6400
Mailing Address - Fax:630-355-6522
Practice Address - Street 1:1247 RICKERT DR
Practice Address - Street 2:STE 100
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-1008
Practice Address - Country:US
Practice Address - Phone:630-355-6400
Practice Address - Fax:630-355-6522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
IL0540049763336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2022622OtherPK
IL=========001Medicaid