Provider Demographics
NPI:1407967094
Name:BOROWIAK IGA FOODLINER INC
Entity Type:Organization
Organization Name:BOROWIAK IGA FOODLINER INC
Other - Org Name:BOROWIAK IGA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:DRAEGE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:618-242-7025
Mailing Address - Street 1:500 S 10TH ST
Mailing Address - Street 2:
Mailing Address - City:MT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864
Mailing Address - Country:US
Mailing Address - Phone:618-242-7025
Mailing Address - Fax:618-242-8473
Practice Address - Street 1:500 S 10TH ST
Practice Address - Street 2:
Practice Address - City:MT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864
Practice Address - Country:US
Practice Address - Phone:618-242-7025
Practice Address - Fax:618-242-8473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL4595030001Medicare ID - Type Unspecified