Provider Demographics
NPI:1386242352
Name:LETITRIDE, INC.
Entity type:Organization
Organization Name:LETITRIDE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:TAVEGGIA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:815-945-4211
Mailing Address - Street 1:501 W OAK STREET
Mailing Address - Street 2:
Mailing Address - City:FAIRBURY
Mailing Address - State:IL
Mailing Address - Zip Code:61739
Mailing Address - Country:US
Mailing Address - Phone:815-945-4211
Mailing Address - Fax:815-945-7466
Practice Address - Street 1:501 W OAK STREET
Practice Address - Street 2:
Practice Address - City:FAIRBURY
Practice Address - State:IL
Practice Address - Zip Code:61739
Practice Address - Country:US
Practice Address - Phone:815-945-4211
Practice Address - Fax:815-945-7466
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LETITRIDE, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-10-13
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4737841114002Medicaid