Healthcare Provider Details

I. General information

NPI: 1871546432
Provider Name (Legal Business Name): AMERICAN PHARMACY OF IL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 08/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 N WESTERN AVE
WEST PEORIA IL
61604-5638
US

IV. Provider business mailing address

311 N WESTERN AVE
PEORIA IL
61604
US

V. Phone/Fax

Practice location:
  • Phone: 309-676-6333
  • Fax: 309-676-1928
Mailing address:
  • Phone: 309-676-6333
  • Fax: 309-676-1928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License NumberFA0212237
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number051035850
License Number StateIL

VIII. Authorized Official

Name: MR. MICHAEL W MINESINGER
Title or Position: PRESIDENT
Credential: RPH
Phone: 309-676-6333