Organization
LIFE GATE PHARMACY LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. MICHELLE HERZOG (OWNER)
(708) 557-3155
Entity
Organization
Contact information
Practice address
5241 S CICERO AVE, CHICAGO, IL 60632
(708) 557-3155
(773) 284-6431
Mailing address
8559 W 121ST ST, PALOS PARK, IL 60464-1230
(708) 557-3155
(727) 474-9067
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
036059796
IL
213ES0103X
Foot & Ankle Surgery Podiatrist
Primary
016003225
IL
Other
Enumeration date
03/25/2014
Last updated
09/17/2018
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