Provider Demographics
NPI:1215973128
Name:DENRICH CORP
Entity type:Organization
Organization Name:DENRICH CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, RESIDENT PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-969-2043
Mailing Address - Street 1:2 N CASS AVE
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-1602
Mailing Address - Country:US
Mailing Address - Phone:630-969-2043
Mailing Address - Fax:630-969-2271
Practice Address - Street 1:2 N CASS AVE
Practice Address - Street 2:
Practice Address - City:WESTMONT
Practice Address - State:IL
Practice Address - Zip Code:60559-1602
Practice Address - Country:US
Practice Address - Phone:630-969-2043
Practice Address - Fax:630-969-2271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2009-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0004X
IL0540046273336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1428374OtherNCPDP PROVIDER IDENTIFICATION NUMBER
IL=========001Medicaid