Provider Demographics
NPI:1063447126
Name:DEWAYNE DRUGS INC.
Entity Type:Organization
Organization Name:DEWAYNE DRUGS INC.
Other - Org Name:BARCUS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ARTHUR
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:DE PESA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-425-2400
Mailing Address - Street 1:4708 W 103RD ST
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-4706
Mailing Address - Country:US
Mailing Address - Phone:708-425-2400
Mailing Address - Fax:708-425-3126
Practice Address - Street 1:4708 W 103RD ST
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-4706
Practice Address - Country:US
Practice Address - Phone:708-425-2400
Practice Address - Fax:708-425-3126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0540097803336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL4505620001Medicare NSC