Provider Demographics
NPI:1114478500
Name:5 GUYS RX II LLC
Entity Type:Organization
Organization Name:5 GUYS RX II LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TAL
Authorized Official - Middle Name:
Authorized Official - Last Name:ROZENE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-994-1496
Mailing Address - Street 1:913 NORTHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-5206
Mailing Address - Country:US
Mailing Address - Phone:217-512-2816
Mailing Address - Fax:217-512-2818
Practice Address - Street 1:1 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:IL
Practice Address - Zip Code:61920
Practice Address - Country:US
Practice Address - Phone:217-512-2816
Practice Address - Fax:844-512-2573
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-20
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
IL054.0201713336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2168642OtherPK