Provider Demographics
NPI:1609879097
Name:DECATUR MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:DECATUR MEMORIAL HOSPITAL
Other - Org Name:PHYSICIAN'S PLAZA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHRMCY MGR
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WELCH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:217-876-6252
Mailing Address - Street 1:2300 N EDWARD ST
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-4163
Mailing Address - Country:US
Mailing Address - Phone:217-876-6252
Mailing Address - Fax:217-876-6215
Practice Address - Street 1:2300 N EDWARD ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-4163
Practice Address - Country:US
Practice Address - Phone:217-876-6252
Practice Address - Fax:217-876-6215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-31
Last Update Date:2013-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IL0540113513336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2017369OtherPK
IL=========007Medicaid
IL=========007Medicaid