Provider Demographics
NPI:1760483465
Name:NESSET PAVILION PHARMACY
Entity Type:Organization
Organization Name:NESSET PAVILION PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:B
Authorized Official - Last Name:GEHRT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:847-318-2810
Mailing Address - Street 1:1775 BALLARD RD
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-1005
Mailing Address - Country:US
Mailing Address - Phone:847-318-2810
Mailing Address - Fax:847-318-2795
Practice Address - Street 1:1775 BALLARD RD
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1005
Practice Address - Country:US
Practice Address - Phone:847-318-2810
Practice Address - Fax:847-318-2795
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADVOCATE MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-08-03
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36-4024817003Medicaid
14-40469OtherNABP