Provider Demographics
NPI:1104302249
Name:ROANOKE RX LLC
Entity type:Organization
Organization Name:ROANOKE RX LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:RPH/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TROY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:309-660-5939
Mailing Address - Street 1:PO BOX 1087
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61702-1087
Mailing Address - Country:US
Mailing Address - Phone:309-828-6767
Mailing Address - Fax:309-828-6970
Practice Address - Street 1:322 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:IL
Practice Address - Zip Code:61561-7515
Practice Address - Country:US
Practice Address - Phone:309-923-7711
Practice Address - Fax:309-923-7714
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ROANOKE RX LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-07-12
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054020855333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1494450OtherNCPDP