Provider Demographics
NPI:1750455127
Name:PRINCEVILLE PHARMACY LLC
Entity Type:Organization
Organization Name:PRINCEVILLE PHARMACY LLC
Other - Org Name:PRINCEVILLE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:RPH
Authorized Official - Prefix:
Authorized Official - First Name:CURTIS
Authorized Official - Middle Name:
Authorized Official - Last Name:SHERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:309-446-3292
Mailing Address - Street 1:PO BOX 566
Mailing Address - Street 2:
Mailing Address - City:PRINCEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61559-0566
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:206 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PRINCEVILLE
Practice Address - State:IL
Practice Address - Zip Code:61559-7516
Practice Address - Country:US
Practice Address - Phone:309-385-4955
Practice Address - Fax:309-385-1561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
IL0540144363336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1426471OtherNCPDP PROVIDER IDENTIFICATION NUMBER
1426471OtherNCPDP PROVIDER IDENTIFICATION NUMBER
3898320001Medicare NSC