Provider Demographics
NPI:1710043435
Name:THE CARBONDALE CLINIC PHARMACY
Entity Type:Organization
Organization Name:THE CARBONDALE CLINIC PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ALLAN
Authorized Official - Middle Name:
Authorized Official - Last Name:NORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-549-5361
Mailing Address - Street 1:2601 W MAIN ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-1031
Mailing Address - Country:US
Mailing Address - Phone:618-549-5361
Mailing Address - Fax:618-549-5158
Practice Address - Street 1:2601 W MAIN ST
Practice Address - Street 2:SUITE 101
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1031
Practice Address - Country:US
Practice Address - Phone:618-549-5361
Practice Address - Fax:618-549-5158
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE CARBONDALE CLINIC, S.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-28
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-034485183500000X
IL051-023018183500000X
IL049-083922183700000X
IL049-127699183700000X
IL049-173061183700000X
IL049-156580183700000X
IL049-169519183700000X
IL0054-0095123336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
No183700000XPharmacy Service ProvidersPharmacy TechnicianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1454014OtherNABP
IL1296860001OtherMEDICARE LEGACY