Provider Demographics
NPI:1629180567
Name:MBRX INC
Entity Type:Organization
Organization Name:MBRX INC
Other - Org Name:MEDICAP PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES MBRX PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:R
Authorized Official - Last Name:BARRON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:217-245-1077
Mailing Address - Street 1:1111 W MORTON AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62650-3165
Mailing Address - Country:US
Mailing Address - Phone:217-245-1077
Mailing Address - Fax:217-245-0006
Practice Address - Street 1:1111 W MORTON AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-3165
Practice Address - Country:US
Practice Address - Phone:217-245-1077
Practice Address - Fax:217-245-0006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054014047333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1456765OtherOTHER ID NUMBER-COMMERCIAL NUMBER
IL3116317906265001Medicaid
IL371239851001Medicaid
IL371239851001Medicaid
IL371239851001Medicaid