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General NPI Number Information
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NPI Number | 1366070476
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Entity Type | Organization
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Legal Business Name | PBCC PHARMACY LLC
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Dates
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Enumeration Date | 04/01/2020
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Last Update Date | 04/07/2025
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Provider Practice Location Address
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Address Line | 1500 W WASHINGTON ST STE B
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City | SPRINGFIELD
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State | IL
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Zip | 62702-4756
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Country | US
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Telephone | 217-546-7100
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Fax |
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Provider Business Mailing Address
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Address Line | 105 S AMOS AVE
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City | SPRINGFIELD
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State | IL
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Zip | 62704-1528
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | OSVALDO WESLY
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Credential |
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Telephone | 217-414-1041
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336S0011X
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Taxonomy Name | Specialty 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 | 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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