Provider Demographics
NPI:1346290830
Name:SANDERS PHARMACY
Entity Type:Organization
Organization Name:SANDERS PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:217-427-2156
Mailing Address - Street 1:PO BOX 648
Mailing Address - Street 2:
Mailing Address - City:CATLIN
Mailing Address - State:IL
Mailing Address - Zip Code:61817-0648
Mailing Address - Country:US
Mailing Address - Phone:217-427-2156
Mailing Address - Fax:217-427-5701
Practice Address - Street 1:112 E. VERMILION STREET
Practice Address - Street 2:
Practice Address - City:CATLIN
Practice Address - State:IL
Practice Address - Zip Code:61817-0648
Practice Address - Country:US
Practice Address - Phone:217-427-2156
Practice Address - Fax:217-427-5701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
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
IL1446942OtherNCPDP
IL=========001Medicaid
IL1288540001Medicare ID - Type Unspecified