Provider Demographics
NPI:1639232390
Name:KINGSWAY ENT. INC
Entity Type:Organization
Organization Name:KINGSWAY ENT. INC
Other - Org Name:KINGSWAY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHMOND
Authorized Official - Middle Name:G
Authorized Official - Last Name:NIMAKO-BOATENG
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD, RPH
Authorized Official - Phone:630-236-9502
Mailing Address - Street 1:1677 MONTGOMERY RD
Mailing Address - Street 2:SUITE 110-112
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60504-8802
Mailing Address - Country:US
Mailing Address - Phone:630-236-9502
Mailing Address - Fax:630-236-9512
Practice Address - Street 1:1677 MONTGOMERY RD
Practice Address - Street 2:SUITE 110-112
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-8802
Practice Address - Country:US
Practice Address - Phone:630-236-9502
Practice Address - Fax:630-236-9512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-17
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054015027332B00000X, 3336C0003X, 3336C0004X
IL335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
1476426OtherNCPDP
1476426OtherNCPDP
IL=========001Medicaid
5157970001Medicare NSC