Provider Demographics
NPI:1437648342
Name:WOODWARD CJS PHARMACY INC
Entity Type:Organization
Organization Name:WOODWARD CJS PHARMACY INC
Other - Org Name:LONG TERM CARE ONLY THE MEDICINE SHOPPE #62
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PIC
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:
Authorized Official - Last Name:WOODWARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-259-0085
Mailing Address - Street 1:901 E EDWARDSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:WOOD RIVER
Mailing Address - State:IL
Mailing Address - Zip Code:62095-1823
Mailing Address - Country:US
Mailing Address - Phone:618-259-0085
Mailing Address - Fax:618-259-0089
Practice Address - Street 1:901 E EDWARDSVILLE RD
Practice Address - Street 2:
Practice Address - City:WOOD RIVER
Practice Address - State:IL
Practice Address - Zip Code:62095-1823
Practice Address - Country:US
Practice Address - Phone:618-259-0085
Practice Address - Fax:618-259-0089
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WOODWARD - CJS PHARMACY, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-05-07
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IL0540159163336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2177390OtherPK
IL=========001Medicaid