Provider Demographics
NPI:1720574676
Name:CRITICAL CARE RX, LLC
Entity Type:Organization
Organization Name:CRITICAL CARE RX, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SAM
Authorized Official - Middle Name:
Authorized Official - Last Name:ENLOE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-339-4211
Mailing Address - Street 1:1884 LACKLAND HILL PKWY STE 6
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-3569
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:126 OAK ST
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61602
Practice Address - Country:US
Practice Address - Phone:833-352-0966
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-03
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL54-0209023336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL54-020902OtherPHARMACY LICENSE
IL054.020902OtherPHARMACY