Healthcare Provider Details

I. General information

NPI: 1356561039
Provider Name (Legal Business Name): ILLINI CLINIC PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 07/01/2020
Certification Date: 07/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

855 ILLINI DR SUITE 200
SILVIS IL
61282-2907
US

IV. Provider business mailing address

855 ILLINI DR SUITE 200
SILVIS IL
61282-2907
US

V. Phone/Fax

Practice location:
  • Phone: 309-792-7002
  • Fax: 309-792-7003
Mailing address:
  • Phone: 309-792-7002
  • Fax: 309-792-7003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number054013807
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. JEFFREY R MERIDETH
Title or Position: PRESIDENT
Credential: RPH
Phone: 309-792-7002