Provider Demographics
NPI:1104930098
Name:OLYMPIA FIELDS PHARMACY INC
Entity type:Organization
Organization Name:OLYMPIA FIELDS PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHCY MGR
Authorized Official - Prefix:
Authorized Official - First Name:AKIL
Authorized Official - Middle Name:
Authorized Official - Last Name:GHOGAWALA
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:847-420-3789
Mailing Address - Street 1:966 W 21ST ST
Mailing Address - Street 2:STE 104
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-4511
Mailing Address - Country:US
Mailing Address - Phone:312-226-2266
Mailing Address - Fax:312-226-9766
Practice Address - Street 1:966 W 21ST ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-4511
Practice Address - Country:US
Practice Address - Phone:312-226-2266
Practice Address - Fax:312-226-9766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0002X
IL0540158133336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2023192OtherPK
2023192OtherPK
2023192OtherPK