Provider Demographics
NPI:1194468348
Name:CLEAR CREEK PHARMACY LLC
Entity Type:Organization
Organization Name:CLEAR CREEK PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ZACHARY
Authorized Official - Middle Name:
Authorized Official - Last Name:BUIKEMA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-527-0909
Mailing Address - Street 1:19015 S JODI RD STE A
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-8534
Mailing Address - Country:US
Mailing Address - Phone:877-527-0909
Mailing Address - Fax:
Practice Address - Street 1:19015 S JODI RD STE A
Practice Address - Street 2:
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-8534
Practice Address - Country:US
Practice Address - Phone:877-527-0909
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-15
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL054.022068OtherSTATE LICENSE NUMBER