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General NPI Number Information
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NPI Number | 1407967094
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Entity Type | Organization
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Legal Business Name | BOROWIAK IGA FOODLINER INC
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Dates
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Enumeration Date | 08/31/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 500 S 10TH ST
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City | MT VERNON
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State | IL
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Zip | 62864
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Country | US
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Telephone | 618-242-7025
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Fax | 618-242-8473
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Provider Business Mailing Address
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Address Line | 500 S 10TH ST
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City | MT VERNON
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State | IL
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Zip | 62864
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Country | US
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Telephone | 618-242-7025
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Fax | 618-242-8473
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Authorized Official
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Title or Position | PHARMACIST IN CHARGE MANAGER
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Name | MR. DANIEL ALAN DRAEGE
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Credential | RPH
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Telephone | 618-242-7025
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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 | IL
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