Provider Demographics
NPI:1154418499
Name:GARDNER PHARMACY INC
Entity type:Organization
Organization Name:GARDNER PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CURT
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:TRIZZINO
Authorized Official - Suffix:
Authorized Official - Credentials:MSHSA
Authorized Official - Phone:815-237-2152
Mailing Address - Street 1:122 DEPOT ST
Mailing Address - Street 2:
Mailing Address - City:GARDNER
Mailing Address - State:IL
Mailing Address - Zip Code:60424
Mailing Address - Country:US
Mailing Address - Phone:815-237-2152
Mailing Address - Fax:815-237-0858
Practice Address - Street 1:122 DEPOT
Practice Address - Street 2:
Practice Address - City:GARDNER
Practice Address - State:IL
Practice Address - Zip Code:60424
Practice Address - Country:US
Practice Address - Phone:815-237-2152
Practice Address - Fax:815-237-0858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
IL333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL363771367001Medicaid
IL363771367001Medicaid