Healthcare Provider Details

I. General information

NPI: 1417092099
Provider Name (Legal Business Name): MAIN STREET PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

195 S MAIN ST
LEWISTOWN IL
61542-1412
US

IV. Provider business mailing address

195 S MAIN ST
LEWISTOWN IL
61542-1412
US

V. Phone/Fax

Practice location:
  • Phone: 309-547-3731
  • Fax: 309-547-2040
Mailing address:
  • Phone: 309-547-3731
  • Fax: 309-547-2040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. RONALD JOE MILES
Title or Position: PRESIDENT
Credential: RPH
Phone: 309-547-3731