Healthcare Provider Details

I. General information

NPI: 1467463968
Provider Name (Legal Business Name): LADD PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 07/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 N MAIN
LADD IL
61329
US

IV. Provider business mailing address

PO BOX 555
LADD IL
61329-0555
US

V. Phone/Fax

Practice location:
  • Phone: 815-894-2207
  • Fax: 815-894-2343
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number054009722
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: RICHARD GIACOMELLI
Title or Position: PHARMACIST
Credential: RPH
Phone: 815-894-2207