Provider Demographics
NPI:1629099197
Name:DENMAN COUNTRY DRUG
Entity Type:Organization
Organization Name:DENMAN COUNTRY DRUG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:KYLE
Authorized Official - Last Name:HART
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:217-696-2820
Mailing Address - Street 1:102 PRAIRIE MILLS RD
Mailing Address - Street 2:P.O. BOX #70
Mailing Address - City:GOLDEN
Mailing Address - State:IL
Mailing Address - Zip Code:62339-0070
Mailing Address - Country:US
Mailing Address - Phone:217-696-2820
Mailing Address - Fax:217-696-2821
Practice Address - Street 1:102 PRAIRIE MILLS RD
Practice Address - Street 2:
Practice Address - City:GOLDEN
Practice Address - State:IL
Practice Address - Zip Code:62339-0070
Practice Address - Country:US
Practice Address - Phone:217-696-2820
Practice Address - Fax:217-696-2821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========005Medicaid