Provider Demographics
NPI:1700232394
Name:ONCOLOGY-HEMATOLOGY ASSOCIATES OF CENTRAL ILLINOIS P C
Entity Type:Organization
Organization Name:ONCOLOGY-HEMATOLOGY ASSOCIATES OF CENTRAL ILLINOIS P C
Other - Org Name:ILLINOIS CANCER CARE, PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:HARLOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-243-3404
Mailing Address - Street 1:8940 N WOOD SAGE RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-7822
Mailing Address - Country:US
Mailing Address - Phone:309-243-3019
Mailing Address - Fax:
Practice Address - Street 1:4391 VENTURE DR
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IL
Practice Address - Zip Code:61354-1018
Practice Address - Country:US
Practice Address - Phone:309-243-3403
Practice Address - Fax:309-243-3075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-12
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0002X, 3336S0011X
IL0540198493336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2160136OtherPK
IL320011987OtherSTATE CONTROLLED SUBSTANCE LICENSE