Provider Demographics
NPI:1992855092
Name:INGALLS PROF PHARMACY LLL
Entity Type:Organization
Organization Name:INGALLS PROF PHARMACY LLL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:WITVOET
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:708-915-5166
Mailing Address - Street 1:19550 GOVERNORS HWY
Mailing Address - Street 2:
Mailing Address - City:FLOSSMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60422-2125
Mailing Address - Country:US
Mailing Address - Phone:708-915-8453
Mailing Address - Fax:708-915-8579
Practice Address - Street 1:19550 GOVERNORS HWY
Practice Address - Street 2:
Practice Address - City:FLOSSMOOR
Practice Address - State:IL
Practice Address - Zip Code:60422-2125
Practice Address - Country:US
Practice Address - Phone:708-915-8453
Practice Address - Fax:708-915-8579
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054-0155493336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1478420OtherNABP NUMBER
1478420OtherNABP NUMBER