Provider Demographics
NPI:1427022474
Name:HAROLD RYAN PHARMACY INC
Entity Type:Organization
Organization Name:HAROLD RYAN PHARMACY INC
Other - Org Name:RYAN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:WEBBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-828-4813
Mailing Address - Street 1:1118 E OAKLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-5524
Mailing Address - Country:US
Mailing Address - Phone:309-828-4813
Mailing Address - Fax:309-828-4922
Practice Address - Street 1:1118 E OAKLAND AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-5524
Practice Address - Country:US
Practice Address - Phone:309-828-4813
Practice Address - Fax:309-828-4922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
0370560001Medicare ID - Type Unspecified