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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