Provider Demographics
NPI:1548304207
Name:LOYOLA UNIVERSITY MEDICAL CENTER
Entity type:Organization
Organization Name:LOYOLA UNIVERSITY MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PATIENT CARE PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:SOWDER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:708-327-2167
Mailing Address - Street 1:2160 S 1ST AVE
Mailing Address - Street 2:BLDG 112 ROOM 1301
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153-3328
Mailing Address - Country:US
Mailing Address - Phone:708-327-2167
Mailing Address - Fax:708-327-2188
Practice Address - Street 1:2160 S 1ST AVE
Practice Address - Street 2:BLDG 112 ROOM 1301
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-3328
Practice Address - Country:US
Practice Address - Phone:708-327-2167
Practice Address - Fax:708-327-2188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IL0930130983336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1465055OtherOTHER ID NUMBER-COMMERCIAL NUMBER
1465055OtherOTHER ID NUMBER
IL=========007Medicaid
1465055OtherOTHER ID NUMBER