# PROVENA PHARMACY ELGIN

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1811902455
- **Authorized official:** SATYA RAO RPH (DIR OF PHCY)
- **Authorized official phone:** (847) 695-3200

## Contact information

- **Practice address:** 750 FLETCHER DR, STE 103, ELGIN, IL 60123-4703
- **Practice address phone:** (847) 931-5535
- **Practice address fax:** (849) 622-2072
- **Mailing address:** 750 FLETCHER DR, STE 103, ELGIN, IL 60123-4703

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 3336C0002X | Clinic Pharmacy | 54013758 | IL | — |
| 3336C0003X | Community/Retail Pharmacy | — | NULL | Yes |

## Other

- **Enumeration date:** 07/30/2006
- **Last updated:** 09/11/2025

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 1460803 | OTHER ID NUMBER-COMMERCIAL NUMBER | — |