Provider Demographics
NPI:1932207750
Name:GLEN ELLYN PHARMACY INC
Entity Type:Organization
Organization Name:GLEN ELLYN PHARMACY INC
Other - Org Name:GLEN ELLYN PHARMACY HEALTH CARE SHOPPES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:LISTECKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-469-5200
Mailing Address - Street 1:486 ROOSEVELT ROAD
Mailing Address - Street 2:
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-5611
Mailing Address - Country:US
Mailing Address - Phone:630-469-5200
Mailing Address - Fax:
Practice Address - Street 1:486 ROOSEVELT ROAD
Practice Address - Street 2:
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-5611
Practice Address - Country:US
Practice Address - Phone:630-469-5200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1422891OtherNATIONAL ASSOCIATON OF BO
1422891OtherNATIONAL ASSOCIATON OF BO
IL=========6013701Medicaid
0297880001Medicare ID - Type Unspecified