Provider Demographics
NPI:1104982230
Name:MALL PHARMACY, INC
Entity type:Organization
Organization Name:MALL PHARMACY, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MATT
Authorized Official - Middle Name:R
Authorized Official - Last Name:CUNNINGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-592-7174
Mailing Address - Street 1:1815 S MEYERS RD STE 100
Mailing Address - Street 2:
Mailing Address - City:OAKBROOK TERRACE
Mailing Address - State:IL
Mailing Address - Zip Code:60181-5226
Mailing Address - Country:US
Mailing Address - Phone:800-592-7174
Mailing Address - Fax:877-992-3831
Practice Address - Street 1:1815 S MEYERS RD STE 100
Practice Address - Street 2:
Practice Address - City:OAKBROOK TERRACE
Practice Address - State:IL
Practice Address - Zip Code:60181-5226
Practice Address - Country:US
Practice Address - Phone:800-592-7174
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-01
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0540200793336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1468481OtherNCPDP
IL1468481OtherNCPDP