Provider Demographics
NPI:1760283410
Name:ILLINOIS COMPOUNDING PHARMACY INC
Entity type:Organization
Organization Name:ILLINOIS COMPOUNDING PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:TUSHAR
Authorized Official - Middle Name:
Authorized Official - Last Name:MEHTA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:630-430-3663
Mailing Address - Street 1:310 OTTAWA LN
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-2788
Mailing Address - Country:US
Mailing Address - Phone:630-430-3663
Mailing Address - Fax:
Practice Address - Street 1:1117 S MILWAUKEE AVE STE A2
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-3754
Practice Address - Country:US
Practice Address - Phone:847-242-8281
Practice Address - Fax:847-232-7425
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-20
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy