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Organization
FAGEN PHARMACY 15
Active
Organization
FAGEN PHARMACY 15
Active
Other names
DEMOTTE DRUGS INC
Organization subpart
No
Provider details
NPI number
Authorized official
LARRY WOJCIK (3RD PARTY COORD)
(219) 987-6468
Entity
Organization
Contact information
Practice address
11112 FRONT ST, MOKENA, IL 60448-1562
(708) 479-9333
(708) 479-5633
Mailing address
FAGEN PHARMACY, PO BOX 9830, SALT LAKE CITY, UT 84109-9913
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
54014975
IL
3336C0003X
Community/Retail Pharmacy
—
—
3336L0003X
Long Term Care Pharmacy
Primary
—
—
3336M0002X
Mail Order Pharmacy
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1475880
OTHER ID NUMBER-COMMERCIAL NUMBER
—
Enumeration date
07/21/2006
Last updated
09/11/2025
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