Provider Demographics
NPI:1720107394
Name:PROFESSIONAL PHARMACY INC
Entity Type:Organization
Organization Name:PROFESSIONAL PHARMACY INC
Other - Org Name:PROFESSIONAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:AMIT
Authorized Official - Middle Name:
Authorized Official - Last Name:DHINGRA
Authorized Official - Suffix:
Authorized Official - Credentials:PHRMD
Authorized Official - Phone:708-754-6878
Mailing Address - Street 1:30 E 15TH ST
Mailing Address - Street 2:STE 204
Mailing Address - City:CHICAGO HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60411-3459
Mailing Address - Country:US
Mailing Address - Phone:708-754-6878
Mailing Address - Fax:708-248-6170
Practice Address - Street 1:30 E 15TH ST
Practice Address - Street 2:STE 204
Practice Address - City:CHICAGO HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60411-3459
Practice Address - Country:US
Practice Address - Phone:708-754-6878
Practice Address - Fax:708-248-6170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2012-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
IL0540161323336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1420811OtherNCPDP PROVIDER IDENTIFICATION NUMBER
IL=========001Medicaid
IL=========001Medicaid