Provider Demographics
NPI:1457776148
Name:MT. PROSPECT HEALTH MART CORPORATION
Entity Type:Organization
Organization Name:MT. PROSPECT HEALTH MART CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:SUNG
Authorized Official - Middle Name:S
Authorized Official - Last Name:CHOE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:224-735-2218
Mailing Address - Street 1:1012 S ELMHURST RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-4240
Mailing Address - Country:US
Mailing Address - Phone:224-735-2218
Mailing Address - Fax:224-735-2269
Practice Address - Street 1:1012 S ELMHURST RD
Practice Address - Street 2:
Practice Address - City:MOUNT PROSPECT
Practice Address - State:IL
Practice Address - Zip Code:60056-4240
Practice Address - Country:US
Practice Address - Phone:224-735-2218
Practice Address - Fax:224-735-2269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-04
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy