Provider Demographics
NPI:1063573467
Name:GREENLEAF PHARMACY & HOMECARE LTD
Entity type:Organization
Organization Name:GREENLEAF PHARMACY & HOMECARE LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INCHARGE PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JAGGA
Authorized Official - Middle Name:R
Authorized Official - Last Name:GRANDHI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:847-336-3455
Mailing Address - Street 1:15 TOWER CT STE 195
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-3340
Mailing Address - Country:US
Mailing Address - Phone:847-336-3455
Mailing Address - Fax:847-596-7250
Practice Address - Street 1:15 TOWER CT STE 195
Practice Address - Street 2:
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-3340
Practice Address - Country:US
Practice Address - Phone:847-336-3455
Practice Address - Fax:847-596-7250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid