Healthcare Provider Details

I. General information

NPI: 1407806607
Provider Name (Legal Business Name): MOWEAQUA PHARMACY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 02/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 N PUTNAM ST
MOWEAQUA IL
62550-9482
US

IV. Provider business mailing address

620 N PUTNAM ST
MOWEAQUA IL
62550-9482
US

V. Phone/Fax

Practice location:
  • Phone: 217-768-3832
  • Fax: 217-768-3077
Mailing address:
  • Phone: 217-768-3832
  • Fax: 217-768-3077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number054.014967
License Number StateIL

VIII. Authorized Official

Name: TERRY TRASTER
Title or Position: OWNER
Credential: PHARMD
Phone: 217-768-3832