Provider Demographics
NPI:1861551079
Name:HALSTED & 79TH ST. PHARMACY INC.
Entity type:Organization
Organization Name:HALSTED & 79TH ST. PHARMACY INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TUSHAR
Authorized Official - Middle Name:
Authorized Official - Last Name:MEHTA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:708-450-0400
Mailing Address - Street 1:151 BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:MELROSE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60160-3702
Mailing Address - Country:US
Mailing Address - Phone:708-450-0400
Mailing Address - Fax:708-344-3668
Practice Address - Street 1:151 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-3702
Practice Address - Country:US
Practice Address - Phone:708-450-0400
Practice Address - Fax:708-344-3668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0540149243336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL4099980001Medicare ID - Type Unspecified