Provider Demographics
NPI:1063483451
Name:PAVILION PHARMACY WEST
Entity Type:Organization
Organization Name:PAVILION PHARMACY WEST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:QUIN
Authorized Official - Middle Name:C
Authorized Official - Last Name:HOSTETLER
Authorized Official - Suffix:
Authorized Official - Credentials:R PH
Authorized Official - Phone:217-698-3888
Mailing Address - Street 1:2901 OLD JACKSONVILLE RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-7437
Mailing Address - Country:US
Mailing Address - Phone:217-698-3888
Mailing Address - Fax:217-698-7649
Practice Address - Street 1:2901 OLD JACKSONVILLE RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-7437
Practice Address - Country:US
Practice Address - Phone:217-698-3888
Practice Address - Fax:217-698-7649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========003Medicaid