Fullerton Kedzie Professional Pharmacy

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

License

054-007134 Issued in IL

Legal business name

FULLERTON KEDZIE PROFESSIONAL PHARMACY

Practice address

3153 W Fullerton Ave
Chicago, IL 60647-2809

Phone

(773) 278-6604

Fax

(773) 395-4633

NPI assigned

Feb 11, 2015

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mr. Ettore Boggetto, RPH

Title

Pharmacist-in-Charge

Phone

(773) 278-6604

Specialties & licenses 1

Addresses

Other identifiers 1

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1423612800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1423612800000",
    "number": "1083005078",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3153 W FULLERTON AVE",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606472809",
            "telephone_number": "773-278-6604",
            "fax_number": "773-395-4633"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3153 W FULLERTON AVE",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606472809",
            "telephone_number": "773-278-6604",
            "fax_number": "773-395-4633"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FULLERTON KEDZIE PROFESSIONAL PHARMACY",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-02-11",
        "last_updated": "2015-02-11",
        "status": "A",
        "authorized_official_last_name": "BOGGETTO",
        "authorized_official_first_name": "ETTORE",
        "authorized_official_title_or_position": "PHARMACIST-IN-CHARGE",
        "authorized_official_telephone_number": "773-278-6604",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "RPH"
    },
    "taxonomies": [
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "IL",
            "license": "054-007134",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "355363043002",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Community/Retail Pharmacy in Chicago, IL
• Providers in Chicago, IL by specialty
• Community/Retail Pharmacy in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 11, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.