Provider Demographics
NPI:1609930437
Name:BLUE ISLAND MEDICAL CENTER PHARMACY INC
Entity Type:Organization
Organization Name:BLUE ISLAND MEDICAL CENTER PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THEDORE
Authorized Official - Middle Name:
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-385-6100
Mailing Address - Street 1:13000 S MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:BLUE ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60406
Mailing Address - Country:US
Mailing Address - Phone:708-389-1591
Mailing Address - Fax:
Practice Address - Street 1:13000 S MAPLE ST
Practice Address - Street 2:
Practice Address - City:BLUE ISLAND
Practice Address - State:IL
Practice Address - Zip Code:60406
Practice Address - Country:US
Practice Address - Phone:708-389-1591
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy