Provider Demographics
NPI:1144790791
Name:JAVON BEA HOSPITAL
Entity Type:Organization
Organization Name:JAVON BEA HOSPITAL
Other - Org Name:MERCYHEALTH PHARMACY - RIVERSIDE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-971-6752
Mailing Address - Street 1:8201 E RIVERSIDE BLVD STE 1022
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-2300
Mailing Address - Country:US
Mailing Address - Phone:815-971-1100
Mailing Address - Fax:815-971-9084
Practice Address - Street 1:8201 E RIVERSIDE BLVD STE 1022
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-2300
Practice Address - Country:US
Practice Address - Phone:815-971-1100
Practice Address - Fax:815-971-9084
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERCY HEALTH CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-11-27
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL054020724OtherIL STATE LICENSE
1494842OtherNCPDP