Provider Demographics
NPI:1417142605
Name:BRENT FAMILY PHARMACY INC.
Entity Type:Organization
Organization Name:BRENT FAMILY PHARMACY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:MRS
Authorized Official - First Name:NATALIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:309-873-2965
Mailing Address - Street 1:1204 HIGHWAY 164 EAST
Mailing Address - Street 2:PO BOX 289
Mailing Address - City:OQUAWKA
Mailing Address - State:IL
Mailing Address - Zip Code:61469-0198
Mailing Address - Country:US
Mailing Address - Phone:309-867-3784
Mailing Address - Fax:
Practice Address - Street 1:1204 HIGHWAY 164 EAST
Practice Address - Street 2:
Practice Address - City:OQUAWKA
Practice Address - State:IL
Practice Address - Zip Code:61469-0289
Practice Address - Country:US
Practice Address - Phone:309-867-3784
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-11
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054-0163263336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL20809904001Medicaid
IL215978Medicare PIN
IL20809904001Medicaid