Organization
111TH PHARMA - FAMILY
Active
Other names
111th Pharma Family
Organization subpart
No
Provider details
NPI number
Authorized official
ADELE VANJACKSON (PIC)
(773) 785-5192
Entity
Organization
Contact information
Practice address
11101 S STATE ST, CHICAGO, IL 60628-4206
(773) 785-5192
(773) 821-6970
Mailing address
11101 S STATE ST, CHICAGO, IL 60628-4206
(773) 785-5192
(773) 821-6970
Taxonomy
Speciality
Code
Description
License number
State
3336C0003X
Community/Retail Pharmacy
Primary
054018137
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2141774
PK
—
Enumeration date
10/25/2006
Last updated
08/27/2013
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