Provider Demographics
NPI:1467463968
Name:LADD PHARMACY
Entity Type:Organization
Organization Name:LADD PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:GIACOMELLI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:815-894-2207
Mailing Address - Street 1:PO BOX 555
Mailing Address - Street 2:
Mailing Address - City:LADD
Mailing Address - State:IL
Mailing Address - Zip Code:61329-0555
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:202 N MAIN
Practice Address - Street 2:
Practice Address - City:LADD
Practice Address - State:IL
Practice Address - Zip Code:61329
Practice Address - Country:US
Practice Address - Phone:815-894-2207
Practice Address - Fax:815-894-2343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054009722333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1410365OtherOTHER ID NUMBER-COMMERCIAL NUMBER
1410365OtherOTHER ID NUMBER-COMMERCIAL NUMBER
1410365OtherOTHER ID NUMBER-COMMERCIAL NUMBER