1619245404 NPI number — PLUM STREET PHARMACY

Table of content: (NPI 1619245404)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619245404 NPI number — PLUM STREET PHARMACY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PLUM STREET PHARMACY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619245404
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/09/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
311 PLUM ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARMI
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62821-1632
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-382-8400
Provider Business Mailing Address Fax Number:
618-382-5700

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
311 PLUM ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARMI
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62821-1632
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-382-8400
Provider Business Practice Location Address Fax Number:
618-382-5700
Provider Enumeration Date:
12/07/2011

Additional Information

Authorized Official

Authorized Official Last Name:
GEE
Authorized Official First Name:
DON
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACIST/OWNER
Authorized Official Telephone Number:
618-382-8330

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  054.017833 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 349683015001 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2132742 . This is a "PK" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com