MEDICARE: BRATLAND'S PRESCRIPTION SHOP INC

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	332B00000X	Durable Medical Equipment & Medical Supplies
2	3336C0003X	Community/Retail Pharmacy	5410069	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5410069	OTHER	IL	PHARMACY LICEASE
2	1459999	OTHER		NABP

General Provider Information

NPI Number	:	1831160357
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRATLAND'S PRESCRIPTION SHOP INC

Provider Business Mailing Address
First Line	:	8 E NORTH ST
Second Line	:
City	:	DANVILLE
State	:	IL
Zip	:	61832-5804
Country	:	US
Telephone Number	:	217-442-2472
Fax Number	:	217-442-2477

Provider Business Practice Location Address
First Line	:	8 E NORTH ST
Second Line	:
City	:	DANVILLE
State	:	IL
Zip	:	61832-5804
Country	:	US
Telephone Number	:	217-442-2472
Fax Number	:	217-442-2477

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. LEO BRATLAND
Credential	:	RPH
Telephone Number	:	217-442-2472

Provider Enumeration Date	:	02/01/2006
Last Update Date	:	03/07/2023

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