Provider Demographics
NPI:1912001967
Name:BOLINGBROOK PHARMACY INC
Entity Type:Organization
Organization Name:BOLINGBROOK PHARMACY INC
Other - Org Name:BOLINGBROOK PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:RPH/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:SINGLETARY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-759-6464
Mailing Address - Street 1:402 W BOUGHTON RD
Mailing Address - Street 2:STE C
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-1872
Mailing Address - Country:US
Mailing Address - Phone:630-759-6464
Mailing Address - Fax:630-759-1780
Practice Address - Street 1:402 W BOUGHTON RD
Practice Address - Street 2:STE C
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-1872
Practice Address - Country:US
Practice Address - Phone:630-759-6464
Practice Address - Fax:630-759-1780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IL0540055943336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2022733OtherPK
2022733OtherPK
IL=========001Medicaid