111TH Pharma - Family
Organization Active NPI Community/Retail Pharmacy · Chicago, IL
NPI 1255415386 · NPPES record last updated Aug 27, 2013
Key facts
- NPI
- 1255415386
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Community/Retail Pharmacy 3336C0003X
- License
- 054018137 (IL)
- Legal business name
- 111TH PHARMA - FAMILY
- Practice address
- 11101 S State St
Chicago, IL 60628-4206 - Phone
- (773) 785-5192
- Fax
- (773) 821-6970
- NPI assigned
- Oct 25, 2006
- Organization subpart
- No
Authorized official
- Name
- Adele Vanjackson
- Title
- Pic
- Phone
- (773) 785-5192
Corporate family (same tax ID) 1
National Provider Directory
- Tax ID family
- 111TH Pharma - Family
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Community/Retail Pharmacy | 3336C0003X | 054018137 | IL | Yes |
Addresses
Primary practice location
11101 S State St
Chicago, IL 60628-4206
Mailing address
11101 S State St
Chicago, IL 60628-4206
Phone (773) 785-5192
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 2141774 | Other | PK |
Other names
- 111th Pharma Family
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Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Aug 27, 2013. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.