Provider Demographics
NPI:1700014446
Name:EXTENDED PHARMACY LLC
Entity Type:Organization
Organization Name:EXTENDED PHARMACY LLC
Other - Org Name:EXTENDED PHARMACY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:SPIRES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-676-4831
Mailing Address - Street 1:121 STATE ST STE 1A
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61602-1547
Mailing Address - Country:US
Mailing Address - Phone:309-676-4831
Mailing Address - Fax:309-676-7014
Practice Address - Street 1:121 STATE ST STE 1A
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61602-1547
Practice Address - Country:US
Practice Address - Phone:309-676-4831
Practice Address - Fax:309-676-7014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-01
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN64002202A333600000X
IL0540167043336L0003X
MO20150447923336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2120962OtherPK
2120962OtherPK