Healthcare Provider Details

I. General information

NPI: 1366070476
Provider Name (Legal Business Name): PBCC PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2020
Last Update Date: 04/07/2025
Certification Date: 04/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 W WASHINGTON ST STE B
SPRINGFIELD IL
62702-4756
US

IV. Provider business mailing address

105 S AMOS AVE
SPRINGFIELD IL
62704-1528
US

V. Phone/Fax

Practice location:
  • Phone: 217-546-7100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VIII. Authorized Official

Name: OSVALDO WESLY
Title or Position: MEDICAL DIRECTOR
Credential:
Phone: 217-414-1041