MEDICARE: BENNER FAMILY PHARMACY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies	203000583	IL
2	3336C0003X	Community/Retail Pharmacy	054013074	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1454711	OTHER		NCPDP
2	403344	OTHER		JOINT COMMISSION ACCREDIT

General Provider Information

NPI Number	:	1841224003
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BENNER FAMILY PHARMACY

Provider Business Mailing Address
First Line	:	113 W MICHIGAN ST
Second Line	:
City	:	OTTAWA
State	:	IL
Zip	:	61350-2028
Country	:	US
Telephone Number	:	815-434-5355
Fax Number	:	815-434-9457

Provider Business Practice Location Address
First Line	:	113 W MICHIGAN ST
Second Line	:
City	:	OTTAWA
State	:	IL
Zip	:	61350-2028
Country	:	US
Telephone Number	:	815-434-5355
Fax Number	:	815-434-9457

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JOHN GROESBECK III
Credential	:	RPH
Telephone Number	:	815-434-5355

Provider Enumeration Date	:	07/11/2006
Last Update Date	:	12/26/2019

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Directions to “BENNER FAMILY PHARMACY ” Practice Location

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