Provider Demographics
NPI:1396243317
Name:HARDIN COUNTY PHARMACY LLC
Entity type:Organization
Organization Name:HARDIN COUNTY PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PIC/AO
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:ETIENNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-285-6618
Mailing Address - Street 1:7 FERRELL RD
Mailing Address - Street 2:
Mailing Address - City:ROSICLARE
Mailing Address - State:IL
Mailing Address - Zip Code:62982-1006
Mailing Address - Country:US
Mailing Address - Phone:618-285-6618
Mailing Address - Fax:618-285-3147
Practice Address - Street 1:226 S ADAMS ST
Practice Address - Street 2:
Practice Address - City:GOLCONDA
Practice Address - State:IL
Practice Address - Zip Code:62938-1109
Practice Address - Country:US
Practice Address - Phone:618-683-8253
Practice Address - Fax:618-683-8239
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-24
Last Update Date:2018-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IL0540206823336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2175582OtherPK
2175582OtherPK