Healthcare Provider Details

I. General information

NPI: 1790892818
Provider Name (Legal Business Name): PEKIN PROHEALTH INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 04/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 S 13TH ST
PEKIN IL
61554-4936
US

IV. Provider business mailing address

600 S 13TH ST
PEKIN IL
61554-4936
US

V. Phone/Fax

Practice location:
  • Phone: 309-347-9455
  • Fax: 309-347-1886
Mailing address:
  • Phone: 309-347-9455
  • Fax: 309-347-1886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number054009001
License Number StateIL

VIII. Authorized Official

Name: MR. BOB HALEY
Title or Position: PRESIDENT
Credential:
Phone: 309-347-1151