Provider Demographics
NPI:1972120921
Name:SYMBRIA RX GREAT LAKES SOUTH LLC
Entity Type:Organization
Organization Name:SYMBRIA RX GREAT LAKES SOUTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAY
Authorized Official - Middle Name:
Authorized Official - Last Name:MANDRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-981-8091
Mailing Address - Street 1:28100 TORCH PKWY STE 600
Mailing Address - Street 2:
Mailing Address - City:WARRENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60555-4030
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1596 HANCOCK AVE
Practice Address - Street 2:
Practice Address - City:APOLLO
Practice Address - State:PA
Practice Address - Zip Code:15613-8404
Practice Address - Country:US
Practice Address - Phone:724-568-4144
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-25
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy