Provider Demographics
NPI:1174674568
Name:MARTIN BEARDSTOWN PHARMACY, LTD.
Entity Type:Organization
Organization Name:MARTIN BEARDSTOWN PHARMACY, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:JENNET
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:217-323-3002
Mailing Address - Street 1:118 W 2ND ST
Mailing Address - Street 2:
Mailing Address - City:BEARDSTOWN
Mailing Address - State:IL
Mailing Address - Zip Code:62618-1137
Mailing Address - Country:US
Mailing Address - Phone:217-323-3002
Mailing Address - Fax:217-323-3004
Practice Address - Street 1:118 W 2ND ST
Practice Address - Street 2:
Practice Address - City:BEARDSTOWN
Practice Address - State:IL
Practice Address - Zip Code:62618-1137
Practice Address - Country:US
Practice Address - Phone:217-323-3002
Practice Address - Fax:217-323-3004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
0306180001Medicare ID - Type Unspecified