Healthcare Provider Details

I. General information

NPI: 1487603296
Provider Name (Legal Business Name): PEKIN PRESCRIPTION LABORATORY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 03/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1016 COURT ST
PEKIN IL
61554-4818
US

IV. Provider business mailing address

1016 COURT ST
PEKIN IL
61554-4818
US

V. Phone/Fax

Practice location:
  • Phone: 309-346-2141
  • Fax: 309-346-7903
Mailing address:
  • Phone: 309-346-2141
  • Fax: 309-346-7903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number203-0007711
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number054.017927
License Number StateIL

VIII. Authorized Official

Name: MR. MARK L. PROBASCO
Title or Position: PRESIDENT
Credential: R.PH.
Phone: 309-346-2141