Provider Demographics
NPI:1740211218
Name:CHANNAHON RANCH PHARMACY INC
Entity Type:Organization
Organization Name:CHANNAHON RANCH PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LOUIS
Authorized Official - Middle Name:B
Authorized Official - Last Name:KADUCAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-467-6090
Mailing Address - Street 1:24715 W EAMES ST
Mailing Address - Street 2:
Mailing Address - City:CHANNAHON
Mailing Address - State:IL
Mailing Address - Zip Code:60410-5192
Mailing Address - Country:US
Mailing Address - Phone:815-467-6090
Mailing Address - Fax:815-467-6167
Practice Address - Street 1:24715 W EAMES ST
Practice Address - Street 2:
Practice Address - City:CHANNAHON
Practice Address - State:IL
Practice Address - Zip Code:60410-5192
Practice Address - Country:US
Practice Address - Phone:815-467-6090
Practice Address - Fax:815-467-6167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054004856183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
1278180001Medicare NSC