Provider Demographics
NPI:1558462010
Name:AUSSIEKER GRAUE ROHRER LLC
Entity Type:Organization
Organization Name:AUSSIEKER GRAUE ROHRER LLC
Other - Org Name:MT PULASKI PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:J
Authorized Official - Last Name:AUSSIEKER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:217-792-5081
Mailing Address - Street 1:507 E CHESTNUT
Mailing Address - Street 2:
Mailing Address - City:MT PULASKI
Mailing Address - State:IL
Mailing Address - Zip Code:62548-1008
Mailing Address - Country:US
Mailing Address - Phone:217-792-5081
Mailing Address - Fax:217-792-5182
Practice Address - Street 1:507 E CHESTNUT
Practice Address - Street 2:
Practice Address - City:MT PULASKI
Practice Address - State:IL
Practice Address - Zip Code:62548-1008
Practice Address - Country:US
Practice Address - Phone:217-792-5081
Practice Address - Fax:217-792-5182
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL1224750001Medicare ID - Type Unspecified