Provider Demographics
NPI:1942416938
Name:47TH AND VICENNES PROFESSIONAL
Entity Type:Organization
Organization Name:47TH AND VICENNES PROFESSIONAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMCIST
Authorized Official - Prefix:
Authorized Official - First Name:ZAROOQ
Authorized Official - Middle Name:
Authorized Official - Last Name:SABAYO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-624-0613
Mailing Address - Street 1:504 - 506 E 47TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60653-4208
Mailing Address - Country:US
Mailing Address - Phone:773-624-0613
Mailing Address - Fax:773-624-0204
Practice Address - Street 1:504 E 47TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60653-4208
Practice Address - Country:US
Practice Address - Phone:773-624-0613
Practice Address - Fax:773-624-0204
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0540149423336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy