Provider Demographics
NPI:1134104219
Name:AGELESS RX SYSTEMS LLC
Entity Type:Organization
Organization Name:AGELESS RX SYSTEMS LLC
Other - Org Name:SULIVAN DRUGS OF GILLESPIE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:217-839-2877
Mailing Address - Street 1:103 N JERSEY ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GILLESPIE
Mailing Address - State:IL
Mailing Address - Zip Code:62033
Mailing Address - Country:US
Mailing Address - Phone:217-839-2877
Mailing Address - Fax:217-839-3233
Practice Address - Street 1:103 N JERSEY ST
Practice Address - Street 2:SUITE 101
Practice Address - City:GILLESPIE
Practice Address - State:IL
Practice Address - Zip Code:62033
Practice Address - Country:US
Practice Address - Phone:217-839-2877
Practice Address - Fax:217-839-3233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-12
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
IL0540021393336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2023083OtherPK
IL370647772001Medicaid
0295400001Medicare NSC