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General NPI Number Information
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NPI Number | 1457434532
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Entity Type | Organization
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Legal Business Name | BOARD OF TRUSTEES FOR EASTERN ILLINOIS UNIVERSITY
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Dates
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Enumeration Date | 10/23/2006
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Last Update Date | 03/01/2017
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Provider Practice Location Address
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Address Line | 1102 HUMAN SERVICES BUILDING 600 LINCOLN AVE
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City | CHARLESTON
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State | IL
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Zip | 61920
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Country | US
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Telephone | 217-581-7779
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Fax | 217-581-7780
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Provider Business Mailing Address
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Address Line | 1102 HUMAN SERVICES BUILDING 600 LINCOLN AVE
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City | CHARLESTON
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State | IL
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Zip | 61920
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Country | US
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Telephone | 217-581-7779
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Fax | 217-581-7780
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Authorized Official
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Title or Position | PHARM SUPV
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Name | AMY MALMEN
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Credential | RPH
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Telephone | 217-581-7779
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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 | 3336C0002X
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Taxonomy Name | Clinic Pharmacy
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License Number | 054017107
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License Number State | IL
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