Healthcare Provider Details

I. General information

NPI: 1154418499
Provider Name (Legal Business Name): GARDNER PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 11/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 DEPOT
GARDNER IL
60424
US

IV. Provider business mailing address

122 DEPOT ST
GARDNER IL
60424
US

V. Phone/Fax

Practice location:
  • Phone: 815-237-2152
  • Fax: 815-237-0858
Mailing address:
  • Phone: 815-237-2152
  • Fax: 815-237-0858

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. CURT PAUL TRIZZINO
Title or Position: OWNER
Credential: MSHSA
Phone: 815-237-2152