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General NPI Number Information
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NPI Number | 1417142605
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Entity Type | Organization
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Legal Business Name | BRENT FAMILY PHARMACY INC.
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Dates
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Enumeration Date | 09/11/2007
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Last Update Date | 07/11/2008
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Provider Practice Location Address
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Address Line | 1204 HIGHWAY 164 EAST
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City | OQUAWKA
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State | IL
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Zip | 61469-0289
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Country | US
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Telephone | 309-867-3784
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Fax |
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Provider Business Mailing Address
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Address Line | 1204 HIGHWAY 164 EAST PO BOX 289
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City | OQUAWKA
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State | IL
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Zip | 61469-0198
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Country | US
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Telephone | 309-867-3784
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Fax |
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Authorized Official
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Title or Position | PHARMACIST IN CHARGE
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Name | MRS. NATALIE J JOHNSON
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Credential | R.PH.
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Telephone | 309-873-2965
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 054-016326
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License Number State | IL
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