Organization · NPI-2

111th Pharma-Family

Clinic/Center, Health Services · Chicago, IL

NPI number1659616175
StatusActive
Last updated in NPPESDec 10, 2012

Details

NPI
1659616175
Entity type
Organization (NPI-2)
Legal business name
111th Pharma-Family
Organization subpart
No
Enumeration date
Dec 10, 2012
Last updated
Dec 10, 2012

Taxonomy and licenses

Taxonomy codeDescriptionLicenseStatePrimary
261QH0100X Clinic/Center, Health Services051035317ILYes

Practice location

11101 S State St
Chicago, IL 60628-4206

Phone 708-503-9845

Mailing address

11101 S State St
Chicago, IL 60628-4206

Phone 708-503-9845

Authorized official

Adele Vanjackson
Owner/Pharmacist
7085039845

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