MEDICARE: BRANDT PHARMACY 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	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	054004373	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2022580	OTHER		PK

General Provider Information

NPI Number	:	1881808137
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRANDT PHARMACY INC

Provider Business Mailing Address
First Line	:	101 N STATE ST
Second Line	:
City	:	MARENGO
State	:	IL
Zip	:	60152-2217
Country	:	US
Telephone Number	:	815-568-7242
Fax Number	:	815-568-0428

Provider Business Practice Location Address
First Line	:	101 N STATE ST
Second Line	:
City	:	MARENGO
State	:	IL
Zip	:	60152-2217
Country	:	US
Telephone Number	:	815-568-7242
Fax Number	:	815-568-0428

Authorized Official
Title or Position	:	MGR
Name	:	BRENDA COURTNEY
Credential	:
Telephone Number	:	815-568-7331

Provider Enumeration Date	:	05/09/2007
Last Update Date	:	06/01/2018

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Directions to “BRANDT PHARMACY INC ” Practice Location

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