Provider Demographics
NPI:1508841834
Name:PROFESIONAL PHARMACY MANAGERS LLC
Entity Type:Organization
Organization Name:PROFESIONAL PHARMACY MANAGERS LLC
Other - Org Name:GRANVILLE DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:TYNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-853-4342
Mailing Address - Street 1:PO BOX 340
Mailing Address - Street 2:
Mailing Address - City:GRANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61326-0340
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:314 S MCCOY ST
Practice Address - Street 2:
Practice Address - City:GRANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61326-9333
Practice Address - Country:US
Practice Address - Phone:815-339-2286
Practice Address - Fax:815-339-2288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-09
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0540178773336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1410567OtherNCPDP PROVIDER IDENTIFICATION NUMBER
1410567OtherNCPDP PROVIDER IDENTIFICATION NUMBER
0286020001Medicare NSC