Provider Demographics
NPI:1649387838
Name:PECATONICA PHARMACY INC
Entity Type:Organization
Organization Name:PECATONICA PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:M
Authorized Official - Last Name:WIEGERT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:815-239-1200
Mailing Address - Street 1:PO BOX 550
Mailing Address - Street 2:
Mailing Address - City:PECATONICA
Mailing Address - State:IL
Mailing Address - Zip Code:61063-0550
Mailing Address - Country:US
Mailing Address - Phone:815-239-1200
Mailing Address - Fax:815-239-1011
Practice Address - Street 1:413 MAIN STREET
Practice Address - Street 2:
Practice Address - City:PECATONICA
Practice Address - State:IL
Practice Address - Zip Code:61063-0550
Practice Address - Country:US
Practice Address - Phone:815-239-1200
Practice Address - Fax:815-239-1011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL363129225001Medicaid