Provider Demographics
NPI:1316109721
Name:BANDYS PHARMACY INC
Entity type:Organization
Organization Name:BANDYS PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:BANDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-548-4000
Mailing Address - Street 1:PO BOX 546
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:IL
Mailing Address - Zip Code:62881-0546
Mailing Address - Country:US
Mailing Address - Phone:618-548-4000
Mailing Address - Fax:618-548-3784
Practice Address - Street 1:1415 W WHITTAKER ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:IL
Practice Address - Zip Code:62881-2015
Practice Address - Country:US
Practice Address - Phone:618-548-4000
Practice Address - Fax:618-548-3784
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BANDYS PHARMACY INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-26
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL203000820332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3711163531001Medicaid
IL3711163531001Medicaid