Provider Demographics
NPI:1902934268
Name:CARTAGENA PHARMACY INC
Entity Type:Organization
Organization Name:CARTAGENA PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:KIELAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-274-7885
Mailing Address - Street 1:1505 W DEVON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-1313
Mailing Address - Country:US
Mailing Address - Phone:773-274-7885
Mailing Address - Fax:773-274-7906
Practice Address - Street 1:1505 W DEVON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60660-1313
Practice Address - Country:US
Practice Address - Phone:773-274-7885
Practice Address - Fax:773-274-7906
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2011-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILIL054114483336C0002X
3336M0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1463342OtherOTHER ID NUMBER-COMMERCIAL NUMBER
1463342OtherOTHER ID NUMBER
IL=========003Medicaid