Provider Demographics
NPI:1649501206
Name:COMMUNITY PHARMACY OF CHICAGO RIDGE INC
Entity type:Organization
Organization Name:COMMUNITY PHARMACY OF CHICAGO RIDGE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PIC
Authorized Official - Prefix:DR
Authorized Official - First Name:JAWAD
Authorized Official - Middle Name:H
Authorized Official - Last Name:HAMDAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:708-229-2100
Mailing Address - Street 1:9830 RIDGELAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60415-2667
Mailing Address - Country:US
Mailing Address - Phone:708-229-2100
Mailing Address - Fax:708-229-2101
Practice Address - Street 1:9830 RIDGELAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60415-2667
Practice Address - Country:US
Practice Address - Phone:708-961-4980
Practice Address - Fax:773-890-1802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-21
Last Update Date:2020-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054-016794332B00000X
IL54-016794333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL54-016794OtherIL DEPT OF FINANCIAL AND PROFESSIONAL REGULATION - PHARMACY LICENSE