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General NPI Number Information
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NPI Number | 1205146917
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Entity Type | Organization
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Legal Business Name | ILLINI PHARMACY SERVICES LLC
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Dates
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Enumeration Date | 10/15/2010
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Last Update Date | 02/21/2017
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Provider Practice Location Address
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Address Line | 675 W IMBODEN DR
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City | DECATUR
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State | IL
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Zip | 62521-9068
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Country | US
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Telephone | 217-791-6340
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Fax | 217-791-6568
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Provider Business Mailing Address
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Address Line | 675 W IMBODEN DR
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City | DECATUR
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State | IL
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Zip | 62521-9068
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Country | US
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Telephone | 217-791-6340
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Fax | 217-791-6568
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Authorized Official
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Title or Position | OWNER
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Name | DARRIN SHASTEEN
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Credential | BS PHARMACY
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Telephone | 217-791-6340
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 3336L0003X
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Taxonomy Name | Long Term Care Pharmacy
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License Number | 054.017565
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License Number State | IL
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