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General NPI Number Information
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NPI Number | 1831274513
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Entity Type | Organization
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Legal Business Name | WAUCONDA PHARMACY INC
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Dates
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Enumeration Date | 10/25/2006
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Last Update Date | 11/07/2011
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Provider Practice Location Address
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Address Line | 222 S MAIN ST
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City | WAUCONDA
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State | IL
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Zip | 60084-1828
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Country | US
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Telephone | 847-526-2591
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Fax | 847-526-1598
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Provider Business Mailing Address
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Address Line | 222 S MAIN ST
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City | WAUCONDA
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State | IL
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Zip | 60084-1828
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | TERRY BRUNER
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Credential | RPH
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Telephone | 847-526-2591
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336H0001X
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Taxonomy Name | Home Infusion Therapy 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 | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number |
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License Number State |
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Taxonomy #4
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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 #5
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Taxonomy Code | 3336C0004X
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Taxonomy Name | Compounding Pharmacy
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License Number | 054006291
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License Number State | IL
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