Healthcare Provider Details

I. General information

NPI: 1538259403
Provider Name (Legal Business Name): PETERSBURG PHARMACY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 06/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CENTRE DR SUITE 100
PETERSBURG IL
62675-9467
US

IV. Provider business mailing address

1 CENTRE DR SUITE 100
PETERSBURG IL
62675-9467
US

V. Phone/Fax

Practice location:
  • Phone: 217-632-7777
  • Fax: 217-632-7618
Mailing address:
  • Phone: 217-632-7777
  • Fax: 217-632-7618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number054.015430
License Number StateIL

VIII. Authorized Official

Name: MR. DAVID BAGOT
Title or Position: PHARMACIST/OWNER
Credential: RPH
Phone: 217-632-7777