Provider Demographics
NPI:1114095320
Name:RENES DRUG STORE INC
Entity Type:Organization
Organization Name:RENES DRUG STORE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:MAZZOTTI
Authorized Official - Suffix:
Authorized Official - Credentials:LICENSED REGISTERED
Authorized Official - Phone:217-824-3533
Mailing Address - Street 1:201 WEST MAIN CROSS
Mailing Address - Street 2:
Mailing Address - City:TAYLORVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62568-2247
Mailing Address - Country:US
Mailing Address - Phone:217-824-3533
Mailing Address - Fax:217-824-3492
Practice Address - Street 1:201 WEST MAIN CROSS
Practice Address - Street 2:
Practice Address - City:TAYLORVILLE
Practice Address - State:IL
Practice Address - Zip Code:62568-2247
Practice Address - Country:US
Practice Address - Phone:217-824-3533
Practice Address - Fax:217-824-3492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054005099333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========6256801Medicaid
IL0300520001Medicare NSC