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General NPI Number Information
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NPI Number | 1063483451
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Entity Type | Organization
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Legal Business Name | PAVILION PHARMACY WEST
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Dates
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Enumeration Date | 02/01/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 2901 OLD JACKSONVILLE RD
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City | SPRINGFIELD
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State | IL
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Zip | 62704-7437
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Country | US
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Telephone | 217-698-3888
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Fax | 217-698-7649
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Provider Business Mailing Address
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Address Line | 2901 OLD JACKSONVILLE RD
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City | SPRINGFIELD
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State | IL
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Zip | 62704-7437
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Country | US
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Telephone | 217-698-3888
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Fax | 217-698-7649
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Authorized Official
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Title or Position | MANAGER
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Name | MR. QUIN C HOSTETLER
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Credential | R. PH.
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Telephone | 217-698-3888
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number |
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License Number State | IL
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