Provider Demographics
NPI:1346255999
Name:TREMONT VILLAGE PHARMACY INC
Entity Type:Organization
Organization Name:TREMONT VILLAGE PHARMACY INC
Other - Org Name:MEDICINE SHOPPE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-925-7177
Mailing Address - Street 1:220 W PEARL STREET A
Mailing Address - Street 2:
Mailing Address - City:TREMONT
Mailing Address - State:IL
Mailing Address - Zip Code:61568
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:220 W PEARL STREET A
Practice Address - Street 2:
Practice Address - City:TREMONT
Practice Address - State:IL
Practice Address - Zip Code:61568
Practice Address - Country:US
Practice Address - Phone:309-925-7177
Practice Address - Fax:309-925-7008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL324460553336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1475056OtherOTHER ID NUMBER-COMMERCIAL NUMBER
1475056OtherOTHER ID NUMBER-COMMERCIAL NUMBER
IL=========001Medicaid
1475056OtherOTHER ID NUMBER-COMMERCIAL NUMBER