Provider Demographics
NPI:1265417281
Name:CARLINVILLE HEALTH & PRESCRIPTION SERVICES
Entity type:Organization
Organization Name:CARLINVILLE HEALTH & PRESCRIPTION SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:OWEN
Authorized Official - Middle Name:P
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:217-854-6121
Mailing Address - Street 1:920 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CARLINVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62626-1200
Mailing Address - Country:US
Mailing Address - Phone:217-854-6121
Mailing Address - Fax:217-854-6131
Practice Address - Street 1:920 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CARLINVILLE
Practice Address - State:IL
Practice Address - Zip Code:62626-1200
Practice Address - Country:US
Practice Address - Phone:217-854-6121
Practice Address - Fax:217-854-6131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL545698333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL545698OtherPHARMACY LISCENSE NUMBER
IL=========001Medicaid
IL=========001Medicaid