=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902903560
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HARTIG DRUG CO CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/17/2006
-----------------------------------------------------
Last Update Date | 08/05/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 316 WASHINGTON ST
-----------------------------------------------------
City | PROPHETSTOWN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61277-1184
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-537-2400
-----------------------------------------------------
Fax | 815-537-2404
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 703 MAIN ST
-----------------------------------------------------
City | DUBUQUE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52001-6821
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 563-588-8700
-----------------------------------------------------
Fax | 563-588-8750
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | CHARLES S HARTIG
-----------------------------------------------------
Credential | PHARMD, JD
-----------------------------------------------------
Telephone | 563-588-8700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 054-15922
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------