Provider Demographics
NPI:1861489353
Name:KEDVON PHARMACY INC
Entity Type:Organization
Organization Name:KEDVON PHARMACY INC
Other - Org Name:KEDVON PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VLADLENA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOROL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:773-338-7171
Mailing Address - Street 1:62 S MILWAUKEE AVE
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:IL
Mailing Address - Zip Code:60090-3108
Mailing Address - Country:US
Mailing Address - Phone:773-338-7171
Mailing Address - Fax:773-338-7272
Practice Address - Street 1:62 S MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:IL
Practice Address - Zip Code:60090-3108
Practice Address - Country:US
Practice Address - Phone:773-338-7171
Practice Address - Fax:773-338-7272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-30
Last Update Date:2021-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
IL0540131943336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
1466831OtherNCPDP PROVIDER IDENTIFICATION NUMBER
IL=========001Medicaid
4614040001Medicare NSC