Provider Demographics
NPI:1639159015
Name:BOWERS DRUG STORE INC
Entity Type:Organization
Organization Name:BOWERS DRUG STORE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:L
Authorized Official - Last Name:MALERI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:618-392-3931
Mailing Address - Street 1:205 E MAIN
Mailing Address - Street 2:
Mailing Address - City:OLNEY
Mailing Address - State:IL
Mailing Address - Zip Code:62450
Mailing Address - Country:US
Mailing Address - Phone:618-392-3931
Mailing Address - Fax:618-395-2912
Practice Address - Street 1:205 E MAIN
Practice Address - Street 2:
Practice Address - City:OLNEY
Practice Address - State:IL
Practice Address - Zip Code:62450
Practice Address - Country:US
Practice Address - Phone:618-392-3931
Practice Address - Fax:618-395-2912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
0271450001Medicare ID - Type Unspecified