Provider Demographics
NPI:1306102728
Name:PROPHARM RX INC
Entity type:Organization
Organization Name:PROPHARM RX INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SEC/TRES
Authorized Official - Prefix:
Authorized Official - First Name:MAURICE
Authorized Official - Middle Name:
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-839-2909
Mailing Address - Street 1:113 S MACOUPIN ST
Mailing Address - Street 2:POB 59
Mailing Address - City:GILLESPIE
Mailing Address - State:IL
Mailing Address - Zip Code:62033-1516
Mailing Address - Country:US
Mailing Address - Phone:217-839-2909
Mailing Address - Fax:
Practice Address - Street 1:115 S MACOUPIN ST
Practice Address - Street 2:
Practice Address - City:GILLESPIE
Practice Address - State:IL
Practice Address - Zip Code:62033-1516
Practice Address - Country:US
Practice Address - Phone:217-839-3233
Practice Address - Fax:217-839-3233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-10
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1486617OtherNCPDP PROVIDER IDENTIFICATION NUMBER