Healthcare Provider Details

I. General information

NPI: 1831274513
Provider Name (Legal Business Name): WAUCONDA PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 11/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 S MAIN ST
WAUCONDA IL
60084-1828
US

IV. Provider business mailing address

222 S MAIN ST
WAUCONDA IL
60084-1828
US

V. Phone/Fax

Practice location:
  • Phone: 847-526-2591
  • Fax: 847-526-1598
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number054006291
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code3336H0001X
TaxonomyHome Infusion Therapy Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: TERRY BRUNER
Title or Position: OWNER
Credential: RPH
Phone: 847-526-2591