Provider Demographics
NPI:1992747505
Name:PROCARE 4268 YANKEE, L.L.C.
Entity type:Organization
Organization Name:PROCARE 4268 YANKEE, L.L.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER, PHARMACY ENROLLMENTS
Authorized Official - Prefix:
Authorized Official - First Name:CRISTIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAURICIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-765-1500
Mailing Address - Street 1:104 S MICHIGAN AVE
Mailing Address - Street 2:SUITE 619
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60603-5902
Mailing Address - Country:US
Mailing Address - Phone:312-252-7204
Mailing Address - Fax:312-332-6140
Practice Address - Street 1:104 S MICHIGAN AVE
Practice Address - Street 2:SUITE 619
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60603-5902
Practice Address - Country:US
Practice Address - Phone:312-252-7204
Practice Address - Fax:312-332-6140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054015141332B00000X, 333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL200326858001Medicaid
IL054015141OtherRESIDENT STATE LICENSE #
IL1476820OtherCOMMERCIAL NUMBER
IL320008059OtherRESIDENT STATE C/S LIC #
IL320008059OtherRESIDENT STATE C/S LIC #
IL320008059OtherRESIDENT STATE C/S LIC #