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General NPI Number Information
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NPI Number | 1790892818
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Entity Type | Organization
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Legal Business Name | PEKIN PROHEALTH INC
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Dates
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Enumeration Date | 08/24/2006
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Last Update Date | 04/03/2017
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Provider Practice Location Address
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Address Line | 600 S 13TH ST
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City | PEKIN
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State | IL
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Zip | 61554-4936
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Country | US
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Telephone | 309-347-9455
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Fax | 309-347-1886
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Provider Business Mailing Address
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Address Line | 600 S 13TH ST
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City | PEKIN
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State | IL
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Zip | 61554-4936
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Country | US
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Telephone | 309-347-9455
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Fax | 309-347-1886
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. BOB HALEY
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Credential |
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Telephone | 309-347-1151
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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 | 054009001
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License Number State | IL
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