Provider Demographics
NPI:1992265235
Name:ILLINI CLINIC PHARMACY INC
Entity type:Organization
Organization Name:ILLINI CLINIC PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:MERIDETH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-629-4506
Mailing Address - Street 1:PO BOX 355
Mailing Address - Street 2:
Mailing Address - City:ALPHA
Mailing Address - State:IL
Mailing Address - Zip Code:61413-0355
Mailing Address - Country:US
Mailing Address - Phone:309-629-4506
Mailing Address - Fax:309-629-2611
Practice Address - Street 1:211 S 1ST STREET
Practice Address - Street 2:
Practice Address - City:ALPHA
Practice Address - State:IL
Practice Address - Zip Code:61413
Practice Address - Country:US
Practice Address - Phone:309-629-4506
Practice Address - Fax:309-629-2611
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ILLINI CLINIC PHARMACY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-03-22
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy