Provider Demographics
NPI:1477632826
Name:ROBERT GOLLON
Entity Type:Organization
Organization Name:ROBERT GOLLON
Other - Org Name:BOB'S PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:B
Authorized Official - Last Name:GOLLON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:217-563-2701
Mailing Address - Street 1:116 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:NOKOMIS
Mailing Address - State:IL
Mailing Address - Zip Code:62075-1657
Mailing Address - Country:US
Mailing Address - Phone:217-563-2701
Mailing Address - Fax:217-563-8337
Practice Address - Street 1:116 W STATE ST
Practice Address - Street 2:
Practice Address - City:NOKOMIS
Practice Address - State:IL
Practice Address - Zip Code:62075-1657
Practice Address - Country:US
Practice Address - Phone:217-563-2701
Practice Address - Fax:217-563-8337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0540118963336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid