Provider Demographics
NPI:1790869188
Name:CONSEDINE PHARMACY INC
Entity Type:Organization
Organization Name:CONSEDINE PHARMACY INC
Other - Org Name:CLINGMAN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:NORMAN
Authorized Official - Last Name:CONSEDINE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:815-777-2002
Mailing Address - Street 1:995 GALENA SQUARE DR
Mailing Address - Street 2:
Mailing Address - City:GALENA
Mailing Address - State:IL
Mailing Address - Zip Code:61036-1355
Mailing Address - Country:US
Mailing Address - Phone:815-777-2002
Mailing Address - Fax:815-777-0310
Practice Address - Street 1:995 GALENA SQUARE DR
Practice Address - Street 2:
Practice Address - City:GALENA
Practice Address - State:IL
Practice Address - Zip Code:61036-1355
Practice Address - Country:US
Practice Address - Phone:815-777-2002
Practice Address - Fax:815-777-0310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X, 183500000X, 183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1422738OtherNCPDP
WI33265000Medicaid
WI33265000Medicaid
WI33265000Medicaid