Provider Demographics
NPI:1316157423
Name:MORGAN PARK PHARMACY
Entity type:Organization
Organization Name:MORGAN PARK PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:MR
Authorized Official - First Name:PERRY
Authorized Official - Middle Name:D
Authorized Official - Last Name:ADAMS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:773-821-4646
Mailing Address - Street 1:11157 S HALSTED ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628-3910
Mailing Address - Country:US
Mailing Address - Phone:773-821-4646
Mailing Address - Fax:773-568-5183
Practice Address - Street 1:11157 S HALSTED ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628-3910
Practice Address - Country:US
Practice Address - Phone:773-821-4646
Practice Address - Fax:773-568-5183
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2009-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054011579183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL362687168001Medicaid