Healthcare Provider Details

I. General information

NPI: 1174558688
Provider Name (Legal Business Name): MONTICELLO DRUGS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 04/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 W MAIN ST
MONTICELLO IL
61856-1967
US

IV. Provider business mailing address

109 W MAIN ST
MONTICELLO IL
61856-1967
US

V. Phone/Fax

Practice location:
  • Phone: 217-762-3176
  • Fax: 217-762-2330
Mailing address:
  • Phone: 217-762-3176
  • Fax: 217-762-2330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number18710433
License Number StateIL

VIII. Authorized Official

Name: MR. MARTIN R WOODRUFF
Title or Position: PHARMACIST IN CHARGE
Credential: RPH
Phone: 217-762-3176