Provider Demographics
NPI:1659616175
Name:111TH PHARMA-FAMILY
Entity Type:Organization
Organization Name:111TH PHARMA-FAMILY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:MS
Authorized Official - First Name:ADELE
Authorized Official - Middle Name:
Authorized Official - Last Name:VANJACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:708-503-9845
Mailing Address - Street 1:11101 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628-4206
Mailing Address - Country:US
Mailing Address - Phone:708-503-9845
Mailing Address - Fax:
Practice Address - Street 1:11101 S STATE ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628-4206
Practice Address - Country:US
Practice Address - Phone:708-503-9845
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-10
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051035317261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service