Provider Demographics
NPI:1578652251
Name:GLIDDONS DRUG STORE INC
Entity Type:Organization
Organization Name:GLIDDONS DRUG STORE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:GUSTAGSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:630-365-6500
Mailing Address - Street 1:116 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ELBURN
Mailing Address - State:IL
Mailing Address - Zip Code:60119-9112
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:116 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ELBURN
Practice Address - State:IL
Practice Address - Zip Code:60119-9112
Practice Address - Country:US
Practice Address - Phone:630-365-6500
Practice Address - Fax:630-365-6522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
IL333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Not Answered333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1421902OtherOTHER ID NUMBER-COMMERCIAL NUMBER
IL=========001Medicaid