Provider Demographics
NPI:1285025346
Name:HODELS-RUBENS PHARMACY
Entity type:Organization
Organization Name:HODELS-RUBENS PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RUBEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMUEL
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:815-968-5779
Mailing Address - Street 1:1029 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61101-1417
Mailing Address - Country:US
Mailing Address - Phone:815-968-5779
Mailing Address - Fax:
Practice Address - Street 1:1029 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61101-1417
Practice Address - Country:US
Practice Address - Phone:815-968-5779
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-11
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0540066703336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid