Provider Demographics
NPI:1376802462
Name:ROCK VALLEY COMPOUNDING PHARMACY LLC
Entity Type:Organization
Organization Name:ROCK VALLEY COMPOUNDING PHARMACY LLC
Other - Org Name:ROCK VALLEY COMPOUNDING PHARMACY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:LEHAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:779-423-0542
Mailing Address - Street 1:811 S PERRYVILLE RD UNIT 109
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-4323
Mailing Address - Country:US
Mailing Address - Phone:779-423-0542
Mailing Address - Fax:779-545-2277
Practice Address - Street 1:811 S PERRYVILLE RD UNIT 109
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-4323
Practice Address - Country:US
Practice Address - Phone:779-423-0542
Practice Address - Fax:779-545-2277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-09
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
IL0540182353336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2135285OtherPK
IL362674647002Medicaid