Healthcare Provider Details

I. General information

NPI: 1982957403
Provider Name (Legal Business Name): INDEPENDENCE HOLDING CO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2012
Last Update Date: 10/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 N 5TH ST
SPRINGFIELD IL
62701-1001
US

IV. Provider business mailing address

4650 INDUSTRIAL DR
SPRINGFIELD IL
62703-5318
US

V. Phone/Fax

Practice location:
  • Phone: 217-528-8096
  • Fax: 217-528-8152
Mailing address:
  • Phone: 217-467-8281
  • Fax: 217-467-8297

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number054.014959
License Number StateIL

VIII. Authorized Official

Name: JOHN ENDRIS
Title or Position: PHARMACIST
Credential:
Phone: 217-528-8096