Healthcare Provider Details

I. General information

NPI: 1255142311
Provider Name (Legal Business Name): POLYCLINIC PHARMACY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2025
Last Update Date: 01/22/2025
Certification Date: 01/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 N LOGAN AVE
DANVILLE IL
61832-4360
US

IV. Provider business mailing address

707 N LOGAN AVE
DANVILLE IL
61832-4360
US

V. Phone/Fax

Practice location:
  • Phone: 217-446-3784
  • Fax: 217-446-0370
Mailing address:
  • Phone: 217-446-3784
  • Fax: 217-446-0370

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: INDERJIT S RAKALLA
Title or Position: OWNER/PIC
Credential: RPH
Phone: 217-446-3784