Provider Demographics
NPI:1306924816
Name:TRINITY RETAIL PHARMACY EAST
Entity type:Organization
Organization Name:TRINITY RETAIL PHARMACY EAST
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHRM MANG
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:WESSEL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:309-779-5010
Mailing Address - Street 1:500 JOHN DEERE RD
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6892
Mailing Address - Country:US
Mailing Address - Phone:309-779-5010
Mailing Address - Fax:309-779-5018
Practice Address - Street 1:500 JOHN DEERE RD
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6892
Practice Address - Country:US
Practice Address - Phone:309-779-5010
Practice Address - Fax:309-779-5018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IL0540170233336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2018629OtherPK
2018629OtherPK