Provider Demographics
NPI:1043276082
Name:WELLGROUP HEALTHPARTNERS PHARMACY
Entity type:Organization
Organization Name:WELLGROUP HEALTHPARTNERS PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:LEONARD
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:708-709-6538
Mailing Address - Street 1:333 DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO HTS
Mailing Address - State:IL
Mailing Address - Zip Code:60411-1748
Mailing Address - Country:US
Mailing Address - Phone:708-755-1400
Mailing Address - Fax:708-709-6051
Practice Address - Street 1:333 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:CHICAGO HTS
Practice Address - State:IL
Practice Address - Zip Code:60411-1748
Practice Address - Country:US
Practice Address - Phone:708-755-1400
Practice Address - Fax:708-709-6051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-26
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0540054803336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL362662795001Medicaid
IL203979Medicare ID - Type Unspecified