Provider Demographics
NPI:1679918403
Name:CONVEX PHARMACY, LLC
Entity Type:Organization
Organization Name:CONVEX PHARMACY, LLC
Other - Org Name:CONVEX PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARYAM
Authorized Official - Middle Name:
Authorized Official - Last Name:ALRAZZAQ
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:708-460-4930
Mailing Address - Street 1:14400 JOHN HUMPHREY DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-2897
Mailing Address - Country:US
Mailing Address - Phone:708-460-4930
Mailing Address - Fax:708-460-4932
Practice Address - Street 1:14400 JOHN HUMPHREY DR
Practice Address - Street 2:SUITE 110
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-2897
Practice Address - Country:US
Practice Address - Phone:708-460-4930
Practice Address - Fax:708-460-4932
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-07
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
IL054.0185653336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2140286OtherPK
2140286OtherPK