Provider Demographics
NPI:1972926244
Name:DESNA PHARMACY, INC.
Entity Type:Organization
Organization Name:DESNA PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MARINA
Authorized Official - Middle Name:
Authorized Official - Last Name:FEFERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-845-2180
Mailing Address - Street 1:843 TALL GRASS LN
Mailing Address - Street 2:
Mailing Address - City:MUNDELEIN
Mailing Address - State:IL
Mailing Address - Zip Code:60060-4565
Mailing Address - Country:US
Mailing Address - Phone:847-845-2180
Mailing Address - Fax:
Practice Address - Street 1:307 S MILWAUKEE AVE
Practice Address - Street 2:SUITE 109
Practice Address - City:WHEELING
Practice Address - State:IL
Practice Address - Zip Code:60090-5076
Practice Address - Country:US
Practice Address - Phone:847-229-5477
Practice Address - Fax:847-229-8448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-22
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL332B00000X, 333600000X, 3336C0003X
3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid