Provider Demographics
NPI:1154475986
Name:ILLINOIS DEPARTMENT OF HUMAN SERVICES
Entity Type:Organization
Organization Name:ILLINOIS DEPARTMENT OF HUMAN SERVICES
Other - Org Name:CLYDE CHOATE MENTAL HEALTH DEVELOPMENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:ONSTOTT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:618-202-6708
Mailing Address - Street 1:1000 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ANNA
Mailing Address - State:IL
Mailing Address - Zip Code:62906-1652
Mailing Address - Country:US
Mailing Address - Phone:618-833-5161
Mailing Address - Fax:618-833-3432
Practice Address - Street 1:1000 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ANNA
Practice Address - State:IL
Practice Address - Zip Code:62906-1652
Practice Address - Country:US
Practice Address - Phone:618-833-5161
Practice Address - Fax:618-833-3432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IL0540173223336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2023357OtherPK