Provider Demographics
NPI:1770758930
Name:MEDCENTRIX INC
Entity type:Organization
Organization Name:MEDCENTRIX INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:J
Authorized Official - Last Name:RUTKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:708-333-5388
Mailing Address - Street 1:71 W 156TH ST
Mailing Address - Street 2:SUITE #104
Mailing Address - City:HARVEY
Mailing Address - State:IL
Mailing Address - Zip Code:60426-4260
Mailing Address - Country:US
Mailing Address - Phone:708-333-5388
Mailing Address - Fax:708-915-2095
Practice Address - Street 1:71 W 156TH ST
Practice Address - Street 2:SUITE #104
Practice Address - City:HARVEY
Practice Address - State:IL
Practice Address - Zip Code:60426-4260
Practice Address - Country:US
Practice Address - Phone:708-333-5388
Practice Address - Fax:708-915-2095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-28
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054009589333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========6047701OtherHFS PAYEE NUMBER
IL=========001Medicaid