Provider Demographics
NPI:1730283789
Name:MULCONREYS APOTHECARY
Entity Type:Organization
Organization Name:MULCONREYS APOTHECARY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:MULCONREY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-323-4422
Mailing Address - Street 1:PO BOX 11
Mailing Address - Street 2:
Mailing Address - City:BEARDSTOWN
Mailing Address - State:IL
Mailing Address - Zip Code:62618-0011
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:113 W 3RD ST
Practice Address - Street 2:
Practice Address - City:BEARDSTOWN
Practice Address - State:IL
Practice Address - Zip Code:62618-1142
Practice Address - Country:US
Practice Address - Phone:217-323-4422
Practice Address - Fax:217-323-4480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
IL333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Not Answered333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1443821OtherOTHER ID NUMBER-COMMERCIAL NUMBER
1443821OtherOTHER ID NUMBER-COMMERCIAL NUMBER
IL=========001Medicaid