Healthcare Provider Details

I. General information

NPI: 1619774296
Provider Name (Legal Business Name): ILLINOIS PHARMACISTS MANAGEMENT ENTERPRISES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2025
Last Update Date: 02/28/2025
Certification Date: 02/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 W COOK ST
SPRINGFIELD IL
62704-2526
US

IV. Provider business mailing address

204 W COOK ST
SPRINGFIELD IL
62704-2526
US

V. Phone/Fax

Practice location:
  • Phone: 217-522-7300
  • Fax: 217-522-7349
Mailing address:
  • Phone: 217-522-7300
  • Fax: 217-522-7349

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: GARTH REYNOLDS
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: BSPHARM, RPH
Phone: 217-522-7300