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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