Provider Demographics
NPI:1023464187
Name:5 GUYS RX LLC
Entity type:Organization
Organization Name:5 GUYS RX LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TAL
Authorized Official - Middle Name:
Authorized Official - Last Name:ROZENE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-994-1496
Mailing Address - Street 1:333 W BETHALTO DR STE B
Mailing Address - Street 2:
Mailing Address - City:BETHALTO
Mailing Address - State:IL
Mailing Address - Zip Code:62010-1909
Mailing Address - Country:US
Mailing Address - Phone:618-377-5356
Mailing Address - Fax:618-377-0159
Practice Address - Street 1:333 W BETHALTO DR STE B
Practice Address - Street 2:
Practice Address - City:BETHALTO
Practice Address - State:IL
Practice Address - Zip Code:62010-1909
Practice Address - Country:US
Practice Address - Phone:618-377-5356
Practice Address - Fax:855-380-3588
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-09
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IL054.0199043336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL364151335001Medicaid
2159604OtherPK
2159604OtherPK
4330040001Medicare PIN