Organization
LIFE SOURCE PHARMACY INC
Active
Other names
Life Source Pharmacy, Inc
Organization subpart
No
Provider details
NPI number
Authorized official
PRASHANT PATEL (PRESIDENT)
(773) 321-2656
Entity
Organization
Contact information
Practice address
11238 S WESTERN AVE, CHICAGO, IL 60643-4116
(773) 321-2656
(773) 941-4294
Mailing address
5 OSPREY CT, STREAMWOOD, IL 60107-2813
(773) 321-2656
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
054-017353
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2124980
PK
—
Enumeration date
05/05/2010
Last updated
03/22/2015
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