Provider Demographics
NPI:1265509087
Name:RESURRECTION SERVICES
Entity type:Organization
Organization Name:RESURRECTION SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:USMA
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:708-938-7213
Mailing Address - Street 1:1111 SUPERIOR ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:MELROSE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60160-4138
Mailing Address - Country:US
Mailing Address - Phone:708-938-7213
Mailing Address - Fax:708-681-6178
Practice Address - Street 1:1111 SUPERIOR ST
Practice Address - Street 2:SUITE 103
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-4138
Practice Address - Country:US
Practice Address - Phone:708-938-7213
Practice Address - Fax:708-681-6178
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RESURRECTION SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-29
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X, 183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========004Medicaid