Provider Demographics
NPI:1295754380
Name:CARAVELLO PHARMACY INC
Entity type:Organization
Organization Name:CARAVELLO PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHARMACY MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:J
Authorized Official - Last Name:CARAVELLO
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:309-932-3440
Mailing Address - Street 1:120 EXCHANGE ST
Mailing Address - Street 2:
Mailing Address - City:GALVA
Mailing Address - State:IL
Mailing Address - Zip Code:61434-1710
Mailing Address - Country:US
Mailing Address - Phone:309-932-3440
Mailing Address - Fax:309-932-3220
Practice Address - Street 1:120 EXCHANGE ST
Practice Address - Street 2:
Practice Address - City:GALVA
Practice Address - State:IL
Practice Address - Zip Code:61434-1710
Practice Address - Country:US
Practice Address - Phone:309-932-3440
Practice Address - Fax:309-932-3220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0540111033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========002Medicaid
IL=========002Medicaid