Healthcare Provider Details

I. General information

NPI: 1609879097
Provider Name (Legal Business Name): DECATUR MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2005
Last Update Date: 05/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 N EDWARD ST
DECATUR IL
62526-4163
US

IV. Provider business mailing address

2300 N EDWARD ST
DECATUR IL
62526-4163
US

V. Phone/Fax

Practice location:
  • Phone: 217-876-6252
  • Fax: 217-876-6215
Mailing address:
  • Phone: 217-876-6252
  • Fax: 217-876-6215

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 Number054011351
License Number StateIL

VIII. Authorized Official

Name: STEVEN WELCH
Title or Position: PHRMCY MGR
Credential: RPH
Phone: 217-876-6252