Healthcare Provider Details

I. General information

NPI: 1649387838
Provider Name (Legal Business Name): PECATONICA PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

413 MAIN STREET
PECATONICA IL
61063-0550
US

IV. Provider business mailing address

PO BOX 550
PECATONICA IL
61063-0550
US

V. Phone/Fax

Practice location:
  • Phone: 815-239-1200
  • Fax: 815-239-1011
Mailing address:
  • Phone: 815-239-1200
  • Fax: 815-239-1011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number
License Number StateIL

VIII. Authorized Official

Name: MRS. LAURA M WIEGERT
Title or Position: PRESIDENT
Credential: RPH
Phone: 815-239-1200