Provider Demographics
NPI:1174072276
Name:EYEPOTHECARY
Entity type:Organization
Organization Name:EYEPOTHECARY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:ANNETTE
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:SOLLARS
Authorized Official - Suffix:III
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:773-782-1744
Mailing Address - Street 1:1726 W CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-5000
Mailing Address - Country:US
Mailing Address - Phone:773-782-1744
Mailing Address - Fax:312-733-1744
Practice Address - Street 1:1726 W CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-5000
Practice Address - Country:US
Practice Address - Phone:773-782-1744
Practice Address - Fax:312-733-1744
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-30
Last Update Date:2016-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL04739116335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier