Provider Demographics
NPI:1124161930
Name:DANNY B YATES
Entity type:Organization
Organization Name:DANNY B YATES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DANNY
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:YATES
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:618-524-9672
Mailing Address - Street 1:212 W 7TH ST
Mailing Address - Street 2:
Mailing Address - City:METROPOLIS
Mailing Address - State:IL
Mailing Address - Zip Code:62960-1604
Mailing Address - Country:US
Mailing Address - Phone:618-524-9672
Mailing Address - Fax:618-524-2466
Practice Address - Street 1:212 W 7TH ST
Practice Address - Street 2:
Practice Address - City:METROPOLIS
Practice Address - State:IL
Practice Address - Zip Code:62960-1604
Practice Address - Country:US
Practice Address - Phone:618-524-9672
Practice Address - Fax:618-524-2466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054.007862183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL695380Medicare ID - Type Unspecified