Provider Demographics
NPI:1205973609
Name:HARBOR PHARMACY INC
Entity type:Organization
Organization Name:HARBOR PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:S
Authorized Official - Last Name:HOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-872-5427
Mailing Address - Street 1:1707 7TH ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:WINTHROP HARBOR
Mailing Address - State:IL
Mailing Address - Zip Code:60096-1656
Mailing Address - Country:US
Mailing Address - Phone:847-872-5427
Mailing Address - Fax:847-872-9645
Practice Address - Street 1:1707 7TH ST
Practice Address - Street 2:SUITE 4
Practice Address - City:WINTHROP HARBOR
Practice Address - State:IL
Practice Address - Zip Code:60096-1656
Practice Address - Country:US
Practice Address - Phone:847-872-5427
Practice Address - Fax:847-872-9645
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1428603OtherNCPDP
IL04932338OtherBLUE CROSS BLUE SHIELD
IL04932338OtherBLUE CROSS BLUE SHIELD
IL=========001Medicaid