MEDICARE: DOC'S DRUGS LTC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	054014073	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1482823	OTHER	IL	NCPDP

General Provider Information

NPI Number	:	1235376161
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DOC'S DRUGS LTC

Provider Business Mailing Address
First Line	:	2764 NORTH ROUTE 1-17
Second Line	:	B
City	:	MOMENCE
State	:	IL
Zip	:	60954
Country	:	US
Telephone Number	:	815-472-3223
Fax Number	:	815-472-3253

Provider Business Practice Location Address
First Line	:	2764 NORTH ROUTE 1-17
Second Line	:	B
City	:	MOMENCE
State	:	IL
Zip	:	60954
Country	:	US
Telephone Number	:	815-472-3223
Fax Number	:	815-472-3253

Authorized Official
Title or Position	:	DIRECTOR OF PHARMACY
Name	:	MR. NICK J SARTORIS
Credential	:	B.S. RPH
Telephone Number	:	815-458-6104

Provider Enumeration Date	:	01/14/2009
Last Update Date	:	01/14/2009

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