Provider Demographics
NPI:1275503294
Name:POLYCLINIC PHARMACY INC
Entity Type:Organization
Organization Name:POLYCLINIC PHARMACY INC
Other - Org Name:POLYCLINIC MEDICAL EQUIP CO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:INDERJIT
Authorized Official - Middle Name:S
Authorized Official - Last Name:RAKALLA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:217-477-5712
Mailing Address - Street 1:622 N LOGAN AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61832-4362
Mailing Address - Country:US
Mailing Address - Phone:217-477-5712
Mailing Address - Fax:217-477-5709
Practice Address - Street 1:622 N LOGAN AVE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-4362
Practice Address - Country:US
Practice Address - Phone:217-477-5712
Practice Address - Fax:217-477-5709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-23
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL203000693332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========002Medicaid
IL0195260002Medicare NSC