Healthcare Provider Details

I. General information

NPI: 1407815061
Provider Name (Legal Business Name): MERLE PHARMACY NO. 1, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2006
Last Update Date: 07/02/2024
Certification Date: 07/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 E LOCUST ST SUITE 1
BLOOMINGTON IL
61701-3077
US

IV. Provider business mailing address

203 E LOCUST ST SUITE 1
BLOOMINGTON IL
61701-3077
US

V. Phone/Fax

Practice location:
  • Phone: 309-828-2242
  • Fax: 309-827-4638
Mailing address:
  • Phone: 309-828-2242
  • Fax: 309-827-4638

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number054002430
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number054002430
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number054002430
License Number StateIL

VIII. Authorized Official

Name: MR. WILLIAM M. MARTIN
Title or Position: PRESIDENT
Credential: R.PH.
Phone: 309-828-2242