Healthcare Provider Details

I. General information

NPI: 1316483266
Provider Name (Legal Business Name): SPRINGFIELD CLINIC, LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2017
Last Update Date: 01/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 N 1ST ST RM 4066
SPRINGFIELD IL
62702-3749
US

IV. Provider business mailing address

900 N 1ST ST RM 4066
SPRINGFIELD IL
62702-3749
US

V. Phone/Fax

Practice location:
  • Phone: 217-391-6940
  • Fax:
Mailing address:
  • Phone: 217-391-6940
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number054.020218
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM BREWER
Title or Position: DIRECTOR OF PHARMACY
Credential:
Phone: 217-391-6940