Healthcare Provider Details

I. General information

NPI: 1023464187
Provider Name (Legal Business Name): 5 GUYS RX LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2016
Last Update Date: 12/01/2023
Certification Date: 12/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 W BETHALTO DR STE B
BETHALTO IL
62010-1909
US

IV. Provider business mailing address

333 W BETHALTO DR STE B
BETHALTO IL
62010-1909
US

V. Phone/Fax

Practice location:
  • Phone: 618-377-5356
  • Fax: 855-380-3588
Mailing address:
  • Phone: 618-377-5356
  • Fax: 618-377-0159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number054.019904
License Number StateIL

VIII. Authorized Official

Name: TAL ROZENE
Title or Position: PHARMACIST/OWNER
Credential:
Phone: 217-994-1496