Provider Demographics
NPI:1861413189
Name:FAGEN PHARMACY 15
Entity type:Organization
Organization Name:FAGEN PHARMACY 15
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:3RD PARTY COORD
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:WOJCIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-987-6468
Mailing Address - Street 1:FAGEN PHARMACY
Mailing Address - Street 2:PO BOX 9830
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109-9913
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11112 FRONT ST
Practice Address - Street 2:
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-1562
Practice Address - Country:US
Practice Address - Phone:708-479-9333
Practice Address - Fax:708-479-5633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL54014975333600000X
3336C0003X, 3336L0003X, 3336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Not Answered3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Not Answered3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1475880OtherOTHER ID NUMBER-COMMERCIAL NUMBER
IL=========015Medicaid