Provider Demographics
NPI:1912063959
Name:BELMONT & WESTERN FARMACIA LLC
Entity type:Organization
Organization Name:BELMONT & WESTERN FARMACIA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:KAMLESH
Authorized Official - Middle Name:P
Authorized Official - Last Name:SHETH
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:773-880-5544
Mailing Address - Street 1:2212 W. BELMONT AVE
Mailing Address - Street 2:2212 W. BELMONT AVE
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-6421
Mailing Address - Country:US
Mailing Address - Phone:773-880-5544
Mailing Address - Fax:773-880-1033
Practice Address - Street 1:2212 W. BELMONT AVE
Practice Address - Street 2:2212 W. BELMONT AVE
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-6421
Practice Address - Country:US
Practice Address - Phone:773-880-5544
Practice Address - Fax:773-880-1033
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BELMONT & WESTERN FARMACIA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-27
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054014348333600000X
IL054-016487333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3636236970001Medicaid
IL=========001Medicaid