Healthcare Provider Details

I. General information

NPI: 1043267594
Provider Name (Legal Business Name): AMERICAN DRUG STORES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2006
Last Update Date: 07/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

543 W LIBERTY ST
WAUCONDA IL
60084
US

IV. Provider business mailing address

250 E PARKCENTER BLVD MAILSTOP SEC2-B
BOISE ID
83706-3940
US

V. Phone/Fax

Practice location:
  • Phone: 847-526-1239
  • Fax: 847-526-3883
Mailing address:
  • Phone: 208-395-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number054-009177
License Number StateIL

VIII. Authorized Official

Name: TIFFANY ELIOPULOS
Title or Position: ASSISTANT MANAGER, ENROLLMENT
Credential:
Phone: 208-395-3906