Provider Demographics
NPI:1659457992
Name:NCS HEALTHCARE OF ILLINOIS, LLC
Entity Type:Organization
Organization Name:NCS HEALTHCARE OF ILLINOIS, LLC
Other - Org Name:OMNICARE OF HERRIN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR DIRECTOR, PAYER RELATIONS
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:COLBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-770-2751
Mailing Address - Street 1:1 CVS DR
Mailing Address - Street 2:BOX 1075
Mailing Address - City:WOONSOCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02895-6146
Mailing Address - Country:US
Mailing Address - Phone:401-765-1500
Mailing Address - Fax:
Practice Address - Street 1:120 LOU ANN DR
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-3752
Practice Address - Country:US
Practice Address - Phone:618-942-2921
Practice Address - Fax:618-942-6519
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-30
Last Update Date:2019-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336L0003X
IL0540170443336L0003X
IL0580134913336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY54001029Medicaid
IL1467198OtherNCPDP
IL1467198OtherNCPDP
IL=========001Medicaid