Provider Demographics
NPI:1841304813
Name:DEL LAGO PHARMACY LTD
Entity type:Organization
Organization Name:DEL LAGO PHARMACY LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:BOTHSCHILD
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:847-256-3950
Mailing Address - Street 1:1515 SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-1882
Mailing Address - Country:US
Mailing Address - Phone:847-256-3950
Mailing Address - Fax:847-256-3957
Practice Address - Street 1:1515 SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:WILMETTE
Practice Address - State:IL
Practice Address - Zip Code:60091-1882
Practice Address - Country:US
Practice Address - Phone:847-256-3950
Practice Address - Fax:847-256-3957
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IL0540049613336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1430204OtherNCPDP PROVIDER IDENTIFICATION NUMBER
1430204OtherNCPDP PROVIDER IDENTIFICATION NUMBER
1430204OtherNCPDP PROVIDER IDENTIFICATION NUMBER