Provider Demographics
NPI:1093883290
Name:DOLAN CENTRAL ILLINOIS COMPOUNDING LLC
Entity Type:Organization
Organization Name:DOLAN CENTRAL ILLINOIS COMPOUNDING LLC
Other - Org Name:PRECKSHOT PROFESSIONAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:COREY
Authorized Official - Middle Name:
Authorized Official - Last Name:DOLAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-679-2047
Mailing Address - Street 1:5832 N KNOXVILLE AVE STE E
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-4304
Mailing Address - Country:US
Mailing Address - Phone:309-679-2047
Mailing Address - Fax:309-679-2051
Practice Address - Street 1:5832 N KNOXVILLE AVE STE E
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-4304
Practice Address - Country:US
Practice Address - Phone:309-679-2047
Practice Address - Fax:309-679-2051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054.020600333600000X
WI2099-433336C0003X
IA43943336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2175601OtherPK