Provider Demographics
NPI:1639223084
Name:HUDSON PHARMACY GROUP INC
Entity Type:Organization
Organization Name:HUDSON PHARMACY GROUP INC
Other - Org Name:HUDSON DRUG SHOP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:HUDSON
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:217-379-4858
Mailing Address - Street 1:PO BOX 70
Mailing Address - Street 2:
Mailing Address - City:PAXTON
Mailing Address - State:IL
Mailing Address - Zip Code:60957-0070
Mailing Address - Country:US
Mailing Address - Phone:217-379-4858
Mailing Address - Fax:217-379-3917
Practice Address - Street 1:108 N MARKET ST
Practice Address - Street 2:
Practice Address - City:PAXTON
Practice Address - State:IL
Practice Address - Zip Code:60957-1220
Practice Address - Country:US
Practice Address - Phone:217-379-4858
Practice Address - Fax:217-379-3917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336L0003X
IL0540160813336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2022759OtherPK
IL=========001Medicaid
5849710001Medicare NSC