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General NPI Number Information
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NPI Number | 1497281620
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Entity Type | Organization
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Legal Business Name | KATHERINE SHAW BETHEA HOSPITAL
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Dates
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Enumeration Date | 05/09/2017
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Last Update Date | 05/09/2017
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Provider Practice Location Address
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Address Line | 403 E 1ST ST
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City | DIXON
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State | IL
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Zip | 61021-3116
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Country | US
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Telephone | 815-285-5586
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Fax | 815-285-5923
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Provider Business Mailing Address
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Address Line | 403 E 1ST ST
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City | DIXON
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State | IL
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Zip | 61021-3116
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Country | US
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Telephone | 815-285-5586
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Fax | 815-285-5923
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Authorized Official
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Title or Position | VP/CHIEF ADMINISTRATIVE OFFICER
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Name | MS. JULIE D MANN
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Credential | FACHE
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Telephone | 815-285-5538
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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 | 054.016955
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License Number State | IL
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