Provider Demographics
NPI:1497766034
Name:CAMARATO DRUG INC
Entity Type:Organization
Organization Name:CAMARATO DRUG INC
Other - Org Name:LOGAN PROFESSIONAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMARATO
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:618-993-5555
Mailing Address - Street 1:PO BOX 398
Mailing Address - Street 2:
Mailing Address - City:HERRIN
Mailing Address - State:IL
Mailing Address - Zip Code:62948-0398
Mailing Address - Country:US
Mailing Address - Phone:618-993-5555
Mailing Address - Fax:618-993-6800
Practice Address - Street 1:303 RUSHING DR
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-3749
Practice Address - Country:US
Practice Address - Phone:618-993-5555
Practice Address - Fax:618-993-6800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336M0003X
IL540148263336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2021253OtherPK
2021253OtherPK
4695080001Medicare NSC