Provider Demographics
NPI:1588906507
Name:PILL SHOP PHARMACY INC
Entity type:Organization
Organization Name:PILL SHOP PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANTOINE
Authorized Official - Middle Name:
Authorized Official - Last Name:MOURANI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-659-3588
Mailing Address - Street 1:3535 E NEW YORK ST STE 117
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60504-4466
Mailing Address - Country:US
Mailing Address - Phone:630-618-2048
Mailing Address - Fax:630-618-2394
Practice Address - Street 1:3535 E NEW YORK ST STE 117
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-4466
Practice Address - Country:US
Practice Address - Phone:630-618-2048
Practice Address - Fax:630-618-2394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-18
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0004X, 332B00000X, 333600000X
IL054.0182243336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2139415OtherPK
IL1487873001Medicaid