Provider Demographics
NPI:1972680304
Name:PRO-WEST PHARMACY
Entity Type:Organization
Organization Name:PRO-WEST PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-673-2424
Mailing Address - Street 1:3861 W WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60624-2342
Mailing Address - Country:US
Mailing Address - Phone:773-826-5430
Mailing Address - Fax:
Practice Address - Street 1:3861 W WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60624-2342
Practice Address - Country:US
Practice Address - Phone:773-826-5430
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054-11267333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL4602940001Medicare ID - Type Unspecified