Provider Demographics
NPI:1952460388
Name:ILLINOIS STATE UNIVERSITY
Entity Type:Organization
Organization Name:ILLINOIS STATE UNIVERSITY
Other - Org Name:ISU STUDENT HEALTH SERVICE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:RUPERT
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:309-438-8713
Mailing Address - Street 1:201 N. UNIVERSITY ST
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61790
Mailing Address - Country:US
Mailing Address - Phone:309-438-8713
Mailing Address - Fax:309-438-7569
Practice Address - Street 1:201 N. UNIVERSITY ST
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61790
Practice Address - Country:US
Practice Address - Phone:309-438-8713
Practice Address - Fax:309-438-7569
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IL0540170283336C0003X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2021237OtherPK
IL1999303700Medicaid