Provider Demographics
NPI:1073822326
Name:NELSON DRUG STORE
Entity type:Organization
Organization Name:NELSON DRUG STORE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:815-875-4415
Mailing Address - Street 1:918 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:IL
Mailing Address - Zip Code:61356-1335
Mailing Address - Country:US
Mailing Address - Phone:815-875-4415
Mailing Address - Fax:815-875-4321
Practice Address - Street 1:918 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:IL
Practice Address - Zip Code:61356-1335
Practice Address - Country:US
Practice Address - Phone:815-875-4415
Practice Address - Fax:815-875-4321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-05
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0540000443336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid