Provider Demographics
NPI:1790240489
Name:ST JUDE PHARMACY, INC.
Entity Type:Organization
Organization Name:ST JUDE PHARMACY, INC.
Other - Org Name:ST. JUDE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMMED
Authorized Official - Middle Name:J
Authorized Official - Last Name:ALAHMED
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:815-900-9000
Mailing Address - Street 1:301 MADISON ST STE 114
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-6549
Mailing Address - Country:US
Mailing Address - Phone:815-900-9000
Mailing Address - Fax:815-900-5500
Practice Address - Street 1:301 MADISON ST STE 114
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-6549
Practice Address - Country:US
Practice Address - Phone:815-900-9000
Practice Address - Fax:815-900-5500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-06
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL054021109OtherILLINOIS DEPARTMENT IF FINANCIAL AND PROFESSIONAL REGULATION PHARMACY LICENSE
IL320012950OtherIDFPR ILLINOIC CONTROLLED PHARMACY LICENSE