Provider Demographics
NPI:1295891315
Name:ENGLEWOOD RX PHARMACY, INC.
Entity type:Organization
Organization Name:ENGLEWOOD RX PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ANISH
Authorized Official - Middle Name:
Authorized Official - Last Name:VADIWALA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-994-0247
Mailing Address - Street 1:6508 S HALSTED ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60621-2616
Mailing Address - Country:US
Mailing Address - Phone:773-994-0247
Mailing Address - Fax:773-994-1071
Practice Address - Street 1:6508 S HALSTED ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60621-2616
Practice Address - Country:US
Practice Address - Phone:773-994-0247
Practice Address - Fax:773-994-1071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-01
Last Update Date:2019-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054013612333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL4564810001Medicare NSC