Provider Demographics
NPI:1245703982
Name:LUNA PHARMACY AT MADISON LLC
Entity type:Organization
Organization Name:LUNA PHARMACY AT MADISON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAMIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-353-5047
Mailing Address - Street 1:3171 W MADISON ST STE 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-1809
Mailing Address - Country:US
Mailing Address - Phone:773-435-9905
Mailing Address - Fax:773-340-4435
Practice Address - Street 1:3171 W MADISON ST STE 2
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-1809
Practice Address - Country:US
Practice Address - Phone:773-435-9905
Practice Address - Fax:773-340-4435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-04
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy