Provider Demographics
NPI:1578513834
Name:BOGARD DRUG NO. 5, INC.
Entity Type:Organization
Organization Name:BOGARD DRUG NO. 5, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE SECRETARY
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANNETTE
Authorized Official - Middle Name:T
Authorized Official - Last Name:NIMMO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-637-4487
Mailing Address - Street 1:1102 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61605-3356
Mailing Address - Country:US
Mailing Address - Phone:309-637-4487
Mailing Address - Fax:309-637-9141
Practice Address - Street 1:1102 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61605-3356
Practice Address - Country:US
Practice Address - Phone:309-637-4487
Practice Address - Fax:309-637-9141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1411191OtherNCPDP
IL=========005Medicaid
IL=========005Medicaid