Healthcare Provider Details

I. General information

NPI: 1720356421
Provider Name (Legal Business Name): KEWANEE HOSPITAL PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2011
Last Update Date: 12/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1051 W SOUTH ST
KEWANEE IL
61443-8354
US

IV. Provider business mailing address

1051 WEST SOUTH STREET P O BOX 747
KEWANEE IL
61443-0747
US

V. Phone/Fax

Practice location:
  • Phone: 309-852-7890
  • Fax:
Mailing address:
  • Phone: 309-852-7890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number054017368
License Number StateIL

VIII. Authorized Official

Name: MRS. MARGARET GUSTAFSON
Title or Position: CHEIF EXECUTIVE OFFICER
Credential:
Phone: 309-852-7520