Provider Demographics
NPI:1962413468
Name:PRO PHARMACY INC
Entity type:Organization
Organization Name:PRO PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AUGUSTUS
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWELLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-824-8012
Mailing Address - Street 1:45-47 E FULLERTON AVE
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:IL
Mailing Address - Zip Code:60101-4601
Mailing Address - Country:US
Mailing Address - Phone:773-928-6850
Mailing Address - Fax:773-928-5662
Practice Address - Street 1:45-47 E FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:IL
Practice Address - Zip Code:60101-4601
Practice Address - Country:US
Practice Address - Phone:773-928-6850
Practice Address - Fax:773-928-5662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0002X, 3336L0003X, 3336M0002X, 3336S0011X
IL0540202613336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2021422OtherPK
IL=========001Medicaid
4647820001Medicare NSC