Provider Demographics
NPI:1114288628
Name:MORTON ALWAN PHARMACY LLC
Entity Type:Organization
Organization Name:MORTON ALWAN PHARMACY LLC
Other - Org Name:MORTON ALWAN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MINESINGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-676-6333
Mailing Address - Street 1:419 MAXINE DR
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:IL
Mailing Address - Zip Code:61550-2495
Mailing Address - Country:US
Mailing Address - Phone:309-291-0180
Mailing Address - Fax:309-291-0181
Practice Address - Street 1:419 MAXINE DR
Practice Address - Street 2:
Practice Address - City:MORTON
Practice Address - State:IL
Practice Address - Zip Code:61550-2495
Practice Address - Country:US
Practice Address - Phone:309-291-0180
Practice Address - Fax:309-291-0181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-31
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
IL0540179113336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2135375OtherPK