Provider Demographics
NPI:1689761223
Name:PRAIRIE ONCOLOGY MANAGEMENT SERVICES PHARMACY
Entity Type:Organization
Organization Name:PRAIRIE ONCOLOGY MANAGEMENT SERVICES PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:W
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:217-329-3239
Mailing Address - Street 1:210 W MCKINLEY AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-5858
Mailing Address - Country:US
Mailing Address - Phone:217-329-3239
Mailing Address - Fax:217-876-9829
Practice Address - Street 1:210 W MCKINLEY AVE
Practice Address - Street 2:STE 1
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-5858
Practice Address - Country:US
Practice Address - Phone:217-329-3239
Practice Address - Fax:217-876-9829
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2016-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054014168183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty