Healthcare Provider Details

I. General information

NPI: 1740717719
Provider Name (Legal Business Name): HARDIN COUNTY PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 FERRELL RD
ROSICLARE IL
62982-1006
US

IV. Provider business mailing address

7 FERRELL RD
ROSICLARE IL
62982-1006
US

V. Phone/Fax

Practice location:
  • Phone: 618-285-6618
  • Fax: 618-285-3147
Mailing address:
  • Phone: 618-285-6618
  • Fax: 618-285-3147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number054020393
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. AMANDA LEA ETIENNE
Title or Position: OWNER
Credential: PHARMD
Phone: 618-285-6618