Provider Demographics
NPI:1639188006
Name:POINTCORE, INC.
Entity Type:Organization
Organization Name:POINTCORE, INC.
Other - Org Name:MEDIPARK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:L
Authorized Official - Last Name:MCGREW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-655-2850
Mailing Address - Street 1:800 NE GLEN OAK AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-3255
Mailing Address - Country:US
Mailing Address - Phone:309-655-2850
Mailing Address - Fax:309-655-4878
Practice Address - Street 1:420 NE GLEN OAK AVE
Practice Address - Street 2:STE 102
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603
Practice Address - Country:US
Practice Address - Phone:309-655-3799
Practice Address - Fax:309-655-3072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IL0540093763336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL003Medicaid
IL=========003Medicaid
1430696OtherNCPDP PROVIDER IDENTIFICATION NUMBER