=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467684407
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DC3 PHARMACY PARTNERS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2009
-----------------------------------------------------
Last Update Date | 05/27/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1120 N 6TH ST
-----------------------------------------------------
City | MONMOUTH
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61462-9672
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-734-6979
-----------------------------------------------------
Fax | 309-734-6982
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1120 N 6TH ST
-----------------------------------------------------
City | MONMOUTH
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61462-9672
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-734-6979
-----------------------------------------------------
Fax | 309-734-6982
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACY MANAGER / PIC
-----------------------------------------------------
Name | DANIEL GRACEY
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 309-712-5957
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 054.016746
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------