Healthcare Provider Details

I. General information

NPI: 1639159015
Provider Name (Legal Business Name): BOWERS DRUG STORE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 E MAIN
OLNEY IL
62450
US

IV. Provider business mailing address

205 E MAIN
OLNEY IL
62450
US

V. Phone/Fax

Practice location:
  • Phone: 618-392-3931
  • Fax: 618-395-2912
Mailing address:
  • Phone: 618-392-3931
  • Fax: 618-395-2912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: RICHARD L MALERI
Title or Position: PRESIDENT
Credential: RPH
Phone: 618-392-3931