Provider Demographics
NPI:1841245404
Name:MEDICATE PHARMACY INC
Entity Type:Organization
Organization Name:MEDICATE PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:SCHALTENBRAND
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:618-874-3000
Mailing Address - Street 1:1833 KINGSHIGHWAY
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON PARK
Mailing Address - State:IL
Mailing Address - Zip Code:62204-2135
Mailing Address - Country:US
Mailing Address - Phone:618-874-3000
Mailing Address - Fax:618-874-3103
Practice Address - Street 1:1833 KINGSHIGHWAY
Practice Address - Street 2:
Practice Address - City:WASHINGTON PARK
Practice Address - State:IL
Practice Address - Zip Code:62204-2135
Practice Address - Country:US
Practice Address - Phone:618-874-3000
Practice Address - Fax:618-874-3103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0540143153336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========002Medicaid
IL1009190001Medicare NSC