Healthcare Provider Details

I. General information

NPI: 1063483451
Provider Name (Legal Business Name): PAVILION PHARMACY WEST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 OLD JACKSONVILLE RD
SPRINGFIELD IL
62704-7437
US

IV. Provider business mailing address

2901 OLD JACKSONVILLE RD
SPRINGFIELD IL
62704-7437
US

V. Phone/Fax

Practice location:
  • Phone: 217-698-3888
  • Fax: 217-698-7649
Mailing address:
  • Phone: 217-698-3888
  • Fax: 217-698-7649

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number
License Number StateIL

VIII. Authorized Official

Name: MR. QUIN C HOSTETLER
Title or Position: MANAGER
Credential: R. PH.
Phone: 217-698-3888