Provider Demographics
NPI:1255462156
Name:ILLINOIS DEPARTMENT OF HUMAN
Entity type:Organization
Organization Name:ILLINOIS DEPARTMENT OF HUMAN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIR OF PHRM
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:KATAUSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-786-6982
Mailing Address - Street 1:901 SOUTHWIND DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62703-5125
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:901 SOUTHWIND DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-5125
Practice Address - Country:US
Practice Address - Phone:217-558-0965
Practice Address - Fax:217-558-2532
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2009-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0540146023336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1480590OtherNCPDP PROVIDER IDENTIFICATION NUMBER