Provider Demographics
NPI:1710269022
Name:900 PHARMACY LLC
Entity Type:Organization
Organization Name:900 PHARMACY LLC
Other - Org Name:900 PHARMACY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:VALENCIA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-907-9007
Mailing Address - Street 1:4527 N SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-5608
Mailing Address - Country:US
Mailing Address - Phone:773-907-9009
Mailing Address - Fax:773-907-9001
Practice Address - Street 1:4527 N SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-5608
Practice Address - Country:US
Practice Address - Phone:773-907-9009
Practice Address - Fax:773-907-9001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-13
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0540177333336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1486011OtherNCPDP PROVIDER IDENTIFICATION NUMBER