Provider Demographics
NPI:1720014301
Name:AMB CORP
Entity Type:Organization
Organization Name:AMB CORP
Other - Org Name:GRAYSLAKE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:FARMER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:847-223-8251
Mailing Address - Street 1:161 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:GRAYSLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-1532
Mailing Address - Country:US
Mailing Address - Phone:847-223-8251
Mailing Address - Fax:847-223-1540
Practice Address - Street 1:161 CENTER ST
Practice Address - Street 2:
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030-1532
Practice Address - Country:US
Practice Address - Phone:847-223-8251
Practice Address - Fax:847-223-1540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid