Provider Demographics
NPI:1639184278
Name:JULIANNE A MANUEL
Entity Type:Organization
Organization Name:JULIANNE A MANUEL
Other - Org Name:MASON CITY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JULIANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:MANUEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-482-5985
Mailing Address - Street 1:149 E CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:MASON CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62664-1403
Mailing Address - Country:US
Mailing Address - Phone:217-482-5985
Mailing Address - Fax:217-482-5715
Practice Address - Street 1:149 E CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:MASON CITY
Practice Address - State:IL
Practice Address - Zip Code:62664-1403
Practice Address - Country:US
Practice Address - Phone:217-482-5985
Practice Address - Fax:217-482-5715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IL0540182903336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2142103OtherPK