Basic Information
| Provider Information | |||||||||
| NPI: | 1013366970 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. BERNARD HOSPITAL AMBULATORY CARE CENTER PHARMACY | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 6307 S STEWART AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606213116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7734201560 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6307 S STEWART AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606213116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7734201560 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2016 | ||||||||
| LastUpdateDate: | 06/10/2016 | ||||||||
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| AuthorizedOfficialLastName: | ATOMAH | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | PHARMACY MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7734201561 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST. BERNARD HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PHARMD. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | 054019899 | IL | Y | Suppliers | Pharmacy |
No ID Information.