Provider Demographics
NPI:1265567440
Name:REIDY MEDICAL PHARMACY
Entity type:Organization
Organization Name:REIDY MEDICAL PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:DUANE
Authorized Official - Middle Name:P
Authorized Official - Last Name:REIDY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:708-478-3418
Mailing Address - Street 1:18210 LA GRANGE RD
Mailing Address - Street 2:101
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-7722
Mailing Address - Country:US
Mailing Address - Phone:708-478-3418
Mailing Address - Fax:708-478-4743
Practice Address - Street 1:18210 LA GRANGE RD
Practice Address - Street 2:101
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-7722
Practice Address - Country:US
Practice Address - Phone:708-478-3418
Practice Address - Fax:708-478-4743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2010-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054006056333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid