Provider Demographics
NPI:1134146848
Name:COFFMAN DRUG STORE INC
Entity Type:Organization
Organization Name:COFFMAN DRUG STORE INC
Other - Org Name:COFFMAN DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GEOFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAUER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-324-3255
Mailing Address - Street 1:PO BOX 218
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62056-0218
Mailing Address - Country:US
Mailing Address - Phone:217-556-6396
Mailing Address - Fax:217-342-3242
Practice Address - Street 1:303 N STATE ST
Practice Address - Street 2:
Practice Address - City:LITCHFIELD
Practice Address - State:IL
Practice Address - Zip Code:62056-2002
Practice Address - Country:US
Practice Address - Phone:217-532-5324
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IL0540089353336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1405655OtherNCPDP PROVIDER IDENTIFICATION NUMBER
1405655OtherNCPDP PROVIDER IDENTIFICATION NUMBER
IL=========002Medicaid