Provider Demographics
NPI:1770504094
Name:SCHOLL PHARMACY INC
Entity Type:Organization
Organization Name:SCHOLL PHARMACY INC
Other - Org Name:FAGEN PHARMACY 17
Other - Org Type:Doing Business As
Authorized Official - Title/Position:3RD PARTY COORD
Authorized Official - Prefix:
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:COFFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-987-6468
Mailing Address - Street 1:FAGEN PHARMACY
Mailing Address - Street 2:PO BOX 9830
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109-9913
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4840 W COURT ST
Practice Address - Street 2:
Practice Address - City:MONEE
Practice Address - State:IL
Practice Address - Zip Code:60449-8988
Practice Address - Country:US
Practice Address - Phone:708-534-3343
Practice Address - Fax:708-534-1638
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL54014974333600000X
3336C0003X, 3336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1475905OtherOTHER ID NUMBER-COMMERCIAL NUMBER
1475905OtherOTHER ID NUMBER-COMMERCIAL NUMBER
IL=========017Medicaid
1475905OtherOTHER ID NUMBER-COMMERCIAL NUMBER