Provider Demographics
NPI:1861792129
Name:PHYSICIANS COMMUNITY PHARMACY, INC
Entity type:Organization
Organization Name:PHYSICIANS COMMUNITY PHARMACY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:J
Authorized Official - Last Name:MINGOLELLI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-798-8112
Mailing Address - Street 1:5320 159TH ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:OAK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60452-4705
Mailing Address - Country:US
Mailing Address - Phone:708-798-8112
Mailing Address - Fax:708-535-6396
Practice Address - Street 1:5320 159TH ST
Practice Address - Street 2:SUITE 201
Practice Address - City:OAK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60452-4705
Practice Address - Country:US
Practice Address - Phone:708-798-8112
Practice Address - Fax:708-535-6396
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-02
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3200099463336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy