Provider Demographics
NPI:1730286006
Name:CONDELL MEDICAL CENTER HOME PHARMACY
Entity Type:Organization
Organization Name:CONDELL MEDICAL CENTER HOME PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:M
Authorized Official - Last Name:KRITIKOS
Authorized Official - Suffix:
Authorized Official - Credentials:RN,BSN,MPH
Authorized Official - Phone:847-816-7717
Mailing Address - Street 1:115 W CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-2149
Mailing Address - Country:US
Mailing Address - Phone:847-816-7717
Mailing Address - Fax:847-367-9078
Practice Address - Street 1:28835 N HERKY DR
Practice Address - Street 2:SUITE 101
Practice Address - City:LAKE BLUFF
Practice Address - State:IL
Practice Address - Zip Code:60044-1464
Practice Address - Country:US
Practice Address - Phone:847-680-0688
Practice Address - Fax:847-680-0692
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3336C0003X, 3336H0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Not Answered3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1469647OtherNABP # PHARMACY
IL04921645OtherBLUE CROSS PROVIDER #
IL04921645OtherBLUE CROSS PROVIDER #
IL=========OtherTAX ID #
IL1469647OtherNABP # PHARMACY
ILBT4235594OtherDEA #