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Organization
COOK COUNTY
Active
Organization
COOK COUNTY
Active
Other names
Fantus Health Center Refill Pharmacy
Organization subpart
No
Provider details
NPI number
Authorized official
JOHN JAY SHANNON M.D. (CHIEF EXECUTIVE OFFICER)
(312) 864-6820
Entity
Organization
Contact information
Practice address
1901 W HARRISON ST RM B178, CHICAGO, IL 60612-3714
(312) 864-1625
(312) 864-9288
Mailing address
1901 W HARRISON ST RM B178, CHICAGO, IL 60612-3714
(312) 864-1625
(312) 864-6738
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
Primary
054.017503
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1484930
NCPDP PROVIDER IDENTIFICATION NUMBER
—
Enumeration date
10/08/2010
Last updated
07/20/2015
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