Provider Demographics
NPI:1407815061
Name:MERLE PHARMACY NO. 1, INC.
Entity Type:Organization
Organization Name:MERLE PHARMACY NO. 1, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:M
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:309-828-2242
Mailing Address - Street 1:203 E LOCUST ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-3077
Mailing Address - Country:US
Mailing Address - Phone:309-828-2242
Mailing Address - Fax:309-827-4638
Practice Address - Street 1:203 E LOCUST ST
Practice Address - Street 2:SUITE 1
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-3077
Practice Address - Country:US
Practice Address - Phone:309-828-2242
Practice Address - Fax:309-827-4638
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054002430333600000X, 3336C0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1430925OtherNABP NUMBER
IL054002430OtherSTATE PHARMACY LICENSE
IL032000672OtherCONTROL DRUG LICENSE NO.
AM3585392OtherFEDERAL DEA NUMBER
AM3585392OtherFEDERAL DEA NUMBER
IL032000672OtherCONTROL DRUG LICENSE NO.