Provider Demographics
NPI:1053838458
Name:ILLINI CLINIC PHARMACY INC
Entity Type:Organization
Organization Name:ILLINI CLINIC PHARMACY INC
Other - Org Name:ALWOOD PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PIC
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 ST
Practice Address - Street 2:
Practice Address - City:ALPHA
Practice Address - State:IL
Practice Address - Zip Code:61413-0355
Practice Address - Country:US
Practice Address - Phone:309-629-4506
Practice Address - Fax:309-629-2611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-25
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IL0540204433336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2169798OtherPK
2169798OtherPK