=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871110254
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ILLINI CLINIC PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/01/2020
-----------------------------------------------------
Last Update Date | 11/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 103 N PROSPECT ST
-----------------------------------------------------
City | CAMBRIDGE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61238-1148
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-781-5770
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 855 ILLINI DR STE 200
-----------------------------------------------------
City | SILVIS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61282-2908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 93-792-7002
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DONNA MERIDETH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 309-781-5770
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------