Provider Demographics
NPI:1912091745
Name:MERCER CTY HOSPITAL
Entity type:Organization
Organization Name:MERCER CTY HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:PUTNAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-582-5301
Mailing Address - Street 1:409 N.W. 9TH AVE
Mailing Address - Street 2:OUTPATIENT PHARMACY
Mailing Address - City:ALEDO
Mailing Address - State:IL
Mailing Address - Zip Code:61231
Mailing Address - Country:US
Mailing Address - Phone:309-582-3710
Mailing Address - Fax:309-582-3737
Practice Address - Street 1:409 N.W. 9TH AVE
Practice Address - Street 2:OUTPATIENT PHARMACY
Practice Address - City:ALEDO
Practice Address - State:IL
Practice Address - Zip Code:61231
Practice Address - Country:US
Practice Address - Phone:309-582-3710
Practice Address - Fax:309-582-3737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0930134453336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1452755OtherNCPDP