Provider Demographics
NPI:1265897409
Name:HAC 4 LLC
Entity type:Organization
Organization Name:HAC 4 LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NORMA
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-928-2491
Mailing Address - Street 1:217 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FARMER CITY
Mailing Address - State:IL
Mailing Address - Zip Code:61842-1455
Mailing Address - Country:US
Mailing Address - Phone:309-928-2491
Mailing Address - Fax:309-928-2493
Practice Address - Street 1:217 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FARMER CITY
Practice Address - State:IL
Practice Address - Zip Code:61842-1455
Practice Address - Country:US
Practice Address - Phone:309-928-2491
Practice Address - Fax:309-928-2493
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-15
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IL0540196463336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2155868OtherPK
2155868OtherPK