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General NPI Number Information
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NPI Number | 1477632826
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Entity Type | Organization
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Legal Business Name | ROBERT GOLLON
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Dates
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Enumeration Date | 11/06/2006
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Last Update Date | 03/17/2015
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Provider Practice Location Address
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Address Line | 116 W STATE ST
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City | NOKOMIS
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State | IL
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Zip | 62075-1657
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Country | US
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Telephone | 217-563-2701
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Fax | 217-563-8337
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Provider Business Mailing Address
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Address Line | 116 W STATE ST
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City | NOKOMIS
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State | IL
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Zip | 62075-1657
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Country | US
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Telephone | 217-563-2701
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Fax | 217-563-8337
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Authorized Official
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Title or Position | OWNER
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Name | MR. ROBERT B GOLLON
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Credential | RPH
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Telephone | 217-563-2701
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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 | 054011896
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License Number State | IL
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