Healthcare Provider Details

I. General information

NPI: 1104302249
Provider Name (Legal Business Name): ROANOKE RX LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2018
Last Update Date: 03/16/2022
Certification Date: 03/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

322 N MAIN ST
ROANOKE IL
61561-7515
US

IV. Provider business mailing address

PO BOX 1087
BLOOMINGTON IL
61702-1087
US

V. Phone/Fax

Practice location:
  • Phone: 309-923-7711
  • Fax: 309-923-7714
Mailing address:
  • Phone: 309-828-6767
  • Fax: 309-828-6970

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number054020855
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: TROY WILLIAMS
Title or Position: RPH/OWNER
Credential: RPH
Phone: 309-660-5939