Provider Demographics
NPI:1265863468
Name:LAKE OF DECATUR, INC
Entity Type:Organization
Organization Name:LAKE OF DECATUR, INC
Other - Org Name:COLEE'S CORNER DRUGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:
Authorized Official - Last Name:COLEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-429-5165
Mailing Address - Street 1:845 S ROUTE 51
Mailing Address - Street 2:UNIT B
Mailing Address - City:FORSYTH
Mailing Address - State:IL
Mailing Address - Zip Code:62535-9759
Mailing Address - Country:US
Mailing Address - Phone:217-330-9552
Mailing Address - Fax:217-791-6280
Practice Address - Street 1:845 S ROUTE 51
Practice Address - Street 2:UNIT B
Practice Address - City:FORSYTH
Practice Address - State:IL
Practice Address - Zip Code:62535-9759
Practice Address - Country:US
Practice Address - Phone:217-330-9552
Practice Address - Fax:217-791-6280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-12
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054-0184413336C0003X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy