Provider Demographics
NPI:1407806607
Name:MOWEAQUA PHARMACY PC
Entity Type:Organization
Organization Name:MOWEAQUA PHARMACY PC
Other - Org Name:MOWEAQUA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:TRASTER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:217-768-3832
Mailing Address - Street 1:620 N PUTNAM ST
Mailing Address - Street 2:
Mailing Address - City:MOWEAQUA
Mailing Address - State:IL
Mailing Address - Zip Code:62550-9482
Mailing Address - Country:US
Mailing Address - Phone:217-768-3832
Mailing Address - Fax:217-768-3077
Practice Address - Street 1:620 N PUTNAM ST
Practice Address - Street 2:
Practice Address - City:MOWEAQUA
Practice Address - State:IL
Practice Address - Zip Code:62550-9482
Practice Address - Country:US
Practice Address - Phone:217-768-3832
Practice Address - Fax:217-768-3077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IL054.0149673336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2017582OtherPK
2017582OtherPK
2017582OtherPK
0507430001Medicare NSC