# EDISON MEDICAL PHARMACY INC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** EDISON MEDICAL PHARMACY
- **Organization subpart:** No

## Provider details

- **NPI number:** 1821166067
- **Authorized official:** PRAVINCHANDRA SHAH RPH (RPHOWNER)
- **Authorized official phone:** (773) 533-2535

## Contact information

- **Practice address:** 4240 W MADISON ST, CHICAGO, IL 60624-2288
- **Practice address phone:** (773) 533-2535
- **Practice address fax:** (773) 533-2535
- **Mailing address:** 4240 W MADISON ST, CHICAGO, IL 60624-2288
- **Mailing address phone:** (773) 533-2535
- **Mailing address fax:** (773) 533-2535

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 333600000X | Pharmacy | — | NULL | — |
| 3336C0003X | Community/Retail Pharmacy | 054009337 | IL | Yes |

## Other

- **Enumeration date:** 12/04/2006
- **Last updated:** 03/13/2015

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 2020547 | PK | — |